March 11th, 2013 66-year-old smoker admitted to community hospital with diverticulitis requiring IV antibioticsdischarged on Day 5 to follow-up with PCP. Incidental CT finding of LLL nodule recorded on radiology report, but not addressed by care team or mentioned in discharge summary. Lawsuit filed two years later for delay in diagnosis of metastatic lung cancer. 2 50-year-old male presents to ED with suspected appendicitis, confirmed by CT, which also reveals possible renal mass.
Surgical team performs laparoscopic appendectomy, discharging patient the next morning, without addressing renal incidental finding. No discharge summary to PCP since this was an observation stay. Patient presents 12 months later to PCP with pulmonary mets from metastatic renal cell carcinoma. 3 I. Difficult to Fix Category: PCPs no longer participate directly in hospital care Length of stay (LOS) continues to shorten, so hard copy radiology reports often not posted in chart by discharge date
Short LOS also sets focus on getting the patient discharged, and not on addressing other issues that could be worked up as an outpatient Discharge summaries not consistently required for observation stays PCPs dont want every hospital radiology report to appear in their EMR inbox, or on their desk 4 II. Amenable to Countermeasures Radiology reporting not flagged in most systems to address high risk findings Tracking systems not in place for high risk radiology findings Patients not consistently advised regarding incidental findings of concern
Attending medical staff accountability suboptimal for incidental CT findings 5 Radiologist reads a study and dictates the report Radiologist enters a standard dictation Macro appropriate to the findings and follow-up plan. This Macro contains an ALRT code that reflects the findings and follow-up plan. Receiving and/or sending system can take advantage of this ALRT code to
plan and track follow-up 6 Scope: Lung nodules found on outpatient CT scans Radiology staff use dictation macros for each Fleischner criteria solid lung nodule follow-up recommendation Generated text includes a Pilot ALRT code that reflects the findings 7 Fleischner criteria <=4mm
>4-6mm >6-8mm >8mm Stable/Normal Flag as Abnormal Result in Result Interface Code coming from Value Powerscribe to file in Fleischner #P 1# Abnormal #P 2# Abnormal #P 3#
Abnormal #P 4# Abnormal #P 9# 8 2013 Epic Systems Corporation 9 Registry tracked by QI staff to confirm actual performance of follow-up CT scans 2013 Epic Systems Corporation
10 More than 900 patients currently tracked in registry (Total patient population ~200,000) No patients with follow-up failures to date Certified reminder letters for overdue patients, those that refuse testing, and patients who leave our network
Requires approximately 0.2 FTE to manage current registry 11 Meeting March 11, 2013 at MA Coalition for the Prevention of Medical Errors Attendees: Brady McKee, MD Lahey Clinic Curtis Bakal, MD Lahey Clinic Larry Garber, MD Reliant Medical Group Mike Kelleher, MD Reliant Medical Group Paula Griswold, MPH - MA Coalition for the
Prevention of Medical Errors Effie Brickman, MPA/H - MA Coalition for the Prevention of Medical Errors 12 Pulmonary - solid nodules Pulmonary ground glass lesions Pulmonary mixed (part solid) lesions These are for incidental findings, and not for follow-up of known malignancies 13
Reviewed Fleischner Society criteria for solid pulmonary nodules Reviewed Fleischner Society criteria for subsolid pulmonary nodules Reviewed National Comprehensive Cancer Network criteria for sub-solid pulmonary nodules Decided that each radiologist/organization can choose whichever guidelines they wish to follow. ALRTs will codify just the type of lesions and recommended follow-up
14 Discussed the limits of accuracy in determining lesions size (e.g. Lahey just says, for example, 56mm or 6-7mm) Discussed inconsistency of use in guidelines (e.g. <5mm vs. <=5mm) Discussed that while conveying the size of the lesion could in theory enable automated tracking of lesion size, it would be impossible to know for certain that its the same lesion, and that realistically it would rarely add value to what the radiologists recommend for follow-up. Decided to not convey lesion size in ALRT code 15
Consists of timeframe and modality Differs based on whether a patient is high-risk for malignancy or not Radiologists cant be expected to consistently know whether the patient fits into the high-risk category Decided that each report macro text will include follow-up recommendations for high-risk patient, non-high-risk patients,
as well as a statement of criteria for high risk 16 It was discussed that, while some of the guidelines have ranges (e.g. 6-12 months), these are not useful to the ordering physician or to an automated followup system Decided that radiologist must choose a single integer time interval for ALRT. When the guideline is a range, the radiologist can put the range in the text, but either use the minimum,
maximum, or average of the range in the ALRT. Pilot will try just using the # of months (as opposed to allowing specifying # of weeks) 17 It was felt that radiologists shouldnt be expected to recommend the following details without knowing the patients full clinical history Imaging modality, other than CTs Procedures (biopsy vs. excision) vs. consultation Decided that while the text of the reports
follow-up recommendations could be more prescriptive, the ALRT would specify either: CT Scan (typically in 1 or more months) Follow-up evaluation (typically in 0 months) 18 Modality Separator ##CH3MC#N6MC## ALRT Start No follow-up is designated by a risk plan of either H or N, followed by 0MN
Body Part C=Chest Timeframe 1 or 2 digit Integer + Character: M=Months Risk Plan: H=High N=Not High Time frame
ALRT End Modality: C=CT Scan E=Evaluatio n N=None Risk Plan 19
Uses ## as delimiter which does not typically have another meaning in reports or HL7 1-character lesion could represent any part of the body and is easily found as the first character following ## Decision support rules could identify the pattern Risk-timeframe-modality-# to automatically determine appropriate patient-specific follow-up Timeframe could easily represent days or weeks Modality could easily represent excision, biopsy, or other imaging modalities if desired
20 Each report should have a section labeled Impression Within the impression, there should be text that summarizes the findings Following the findings, there should be text that starts with Recommend (which can be Recommendation or Recommendations), followed by the follow-up recommendations if the patient is high-risk, recommendations if the
patient is not high-risk, the description of what constitutes a high-risk patient, and then the ALRT code. 21 Report to ordering provider flagged to highlight abnormality Abnormal studies ccd to PCP if not the ordering
provider (particularly important in cases ordered by ED, surgeon, or hospitalist) Copies of abnormal studies automatically given to patient, for example, at time of hospital discharge and/or mailed to patient Abnormals ccd to registries for tracking purposes Study rates of contacting patients for follow-up Study rates of obtaining follow-up per radiology recommendations 22 Approval of this minutes presentation Pilot at: Lahey Hospital/Clinic
Reliant Medical Group and St. Vincent Hospital If workable, the present to MA Radiological Society with recommendations to: Use ALRT codes in dictation macros for pulmonary lesions, including text that defines high risk Consider implementing one or more Best Practices 23 Get statewide consensus on minimum lesion size that could warrant a follow-up Improved the conveyance of risk factors (and history) to the radiologist Create standardized letters to patients (similar to mammography letters) that
explain findings, recommended follow-up, risks, benefits, and alternatives Share standard dictation macros for the various lesions 24
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