During the past two years, six Strategic Radiology (SR) member groups explored methods of directly communicating incidental findings (IF) on studies acquired in the emergency department (ED) to patients and their primary care physicians. The project began when Strategic Radiology was named one of 12 recipients of a Coverys Community Healthcare Foundation (CCHF) grant at the end of 2018, with the objective of developing a low-cost program that could be rolled out across the United States.

The CCHF-funded research took place within the auspices of the SR Patient Safety Organization (PSO) under the direction of Lisa Mead, RN, CPHQ, SR-PSO executive director. As Ms. Mead finalizes her report on the research findings, SR is rolling out the service as RadReach™, enabling participating groups, their hospital partners, and other interested Strategic Radiology member groups to offer the service

“It has been very interesting work,” Ms. Mead reports. “Six groups participated in the project and when we wrap up our work in the next couple of weeks, 200,000 reports will have been reviewed. In the midst of all of this, we decided it makes sense to talk about developing a follow-up program that groups can buy into if they or their hospital partners are interested.”

The study participants were: ARA Health Specialists (formerly Asheville Radiology Associates, Asheville, NC), Southeast Radiology Ltd. (Upland, PA), The Hill Medical Corp (Pasadena, CA), Mountain Medical Physician Specialists (Murray, UT), X-Ray Consultants, Northwest Radiology Network (Indianapolis, IN), and Inland Imaging (Spokane, WA).

Responding to a Need

SR is rolling out the program as RadReach™, which can be customized to the setting a practice or provider identifies as important (e.g. ED, outpatient, inpatient, oncology clinic, pulmonary clinic), with a corresponding focus on the reports most likely to yield incidental findings with the greatest potential to harm. For instance, the Coverys grant research focused on studies identified as most likely to yield pulmonary, thyroid, adrenal, and pancreatic lesions found incidentally in the ED, a challenging setting for communicating findings. Patients and their primary care physicians, if known, received a letter alerting them to the need for follow-up.

“I’ve received calls from patients who have been in the ER, got admitted, went to rehab, got home, and six months later said, ‘Wow, this is really important. I didn’t even know that I had this recommendation for follow up’,” Ms. Mead notes. “If someone has seen the recommendation, we know that things go better. We get the follow-up exams performed so that the patient has a definitive diagnosis earlier.”

The problem of overlooked incidental findings has been well documented in the literature. “We know missed opportunities resulting in preventable delay in diagnoses of malignancies occur in one in seven lung cancer diagnoses,” Ms. Mead notes. “We know that there are ED problems in hand-off, in that only about half of the radiologist follow-up recommendations are conveyed to the patient on discharge instructions. They just get buried and lost, and sometimes they aren’t available. Important information such as diagnostic tests is missing on a third to two-thirds of all discharge summaries. Then there are the test results pending at discharge, documented in as many as 65% of discharge summaries.”

Rising imaging volumes have resulted in a concomitant increase in incidental findings. “More than 55% of trauma patients are undergoing whole-body CT, and that is where we find these incidental findings in the ED,” Ms. Mead shares. “There is a significant prevalence in other patient populations—about 9% among screening patients and as high as 31% among patients with known cancer. What I have seen is that about 12.5% of all cases recommend follow-up imaging.”

“We think that all of our recommendations are communicated and followed, but they are not,” says Ms. Mead. “We really want to change the way we communicate so that we can alter the future by using these tools and involve the patients in their care decisions.”  

The ARA Health Specialists Experience

ARA Health Specialists (formerly Asheville Radiology Associates) Chief Operating Officer Joseph Guiffrida reports that the Asheville practice, which serves six Mission Health hospitals in western North Carolina, will become the first RadReach client. Coincidentally, the group had begun a project to communicate incidental findings in the ED before the Coverys research began. “It dovetailed with a project that was already underway here at our practice. We had begun sending out letters to patients for any incidental finding recommendation in the emergency department, so that project continued in parallel with the work we did under the grant. We knew there would be some redundancy, but I’m willing to have patients be a little bit frustrated with me if someone gets a couple of letters about an incidental finding. “Our aim is to make sure patients are getting the appropriate follow-up exams in a timely manner to improve outcomes and help people reach their highest attainable quality of life.”

ARA Health Specialists used technology already in place to pull recommendations out of their imaging reports and looks forward to transitioning to the RadLoop technology, an enabling technology of the Radreach solution. “We are very impressed with RadLoop and excited to bring in a dedicated system that is tailored to this purpose that will help us tighten up our communications and expand the program to inpatient and ambulatory exams,” Guiffrida says. “We are sensitive to how the primary care physicians react to things like this and want to give them their notice prior to notifying the patient to build a coordinated effort with all of caregivers on behalf of the patients.”

As a result of their work on the project, ARA Health Specialists made edits to their report templates so that all radiologists use standardized recommendations in their dictations. “Any incidental finding should have a corresponding recommendation, and that has really improved our rate of capture,” Guiffrida concludes.

Adding Automation

The RadReach program leverages the RadLoop natural language processing follow-up detection algorithm, paired with hands-on review and navigation. Built-in dashboards enable reporting to the practice for quality improvement purposes, and multi-faceted communication options increase the ability to connect with patients and PCPs. Mead is excited about the potential to completely automate the communication process on the PCP side using asynchronous communication that does not contribute to the alert-fatigue seen with many other tools used in health care.

“We can build a scalable system that automatically identifies and tracks follow-up recommendations, and we can, if we want to, automate completely and send these recommendations to the clinician’s smartphone, tablet, desktop, or a letter,” Ms. Mead says. “Asynchronous communication allows the clinician to order the recommended study and get it off their plate and back in our ordering queues.  All of this activity can be documented in the EMR, and, of course, that offers protection to all parties.”

The goal of the program is to increase exam completion rates, move the needle on quality and safety, decrease liability, and increase revenue by driving more of the exams that would not be followed up—without impeding the workflow of the radiologist or the referring clinician. “This program can help you provide your colleagues with explicit instructions for follow-up, including the study type and time frame, delivered so that workflow is not interrupted and even improved on by making it easy to order the follow up exam.”

“The benefit of tracking follow-up on incidental findings is that it increases the recommended exam completion rate by 50% or more,” Ms. Mead shares. “This is a good program for adding value to your communities and your health systems. They may already have navigation, but this tool offers a consolidates, user friendly and ultimately better way.”