Automated Imaging Notification System Close to Fail-Safe

WASHINGTON—One way to ensure that the right parties receive imaging study results and actually look at them is to make notification nearly fail-safe. A system in use at the Veterans Administration Medical Center, Asheville, NC, as well as other VAs, does exactly that, David M. Schuster, MD, staff radiologist at the hospital, said at the 100th annual meeting of the American Roentgen Ray Society.

The system has “zero tolerance for missed results,” he said, and it significantly reduces delays in diagnosis.

Ideally, when a clinician orders an x-ray or other imaging study, the results are transmitted quickly, the clinician looks them up as soon as they come in, and then just as quickly notifies the patient. But in a busy hospital setting, this doesn’t always happen, Dr. Schuster said. Delays can occur at each step of the way.

In the VA medical network, every clinician must be registered in the computer system, he said. Regular communication is sent by e-mail, but when an imaging study is ordered, the request is transmitted by a separate computerized route bearing the clinician’s electronic signature.

When an imaging study is completed, a staffer types the results into the computerized system. The radiologist verifies the report and signs it electronically—at which point the system asks that a code signifying severity be assigned. “If you try to skip over this part, it’ll just take you right back to it,” Dr. Schuster said.

Once the code is assigned, the report is then automatically sent to the ordering clinician. Abnormalities, which include codes for malignancy or possible malignancy, and infection, fracture, and other noncancerous conditions—trigger an alert that appears regularly on the clinician’s screen.

For abnormalities requiring quick action—pneumothorax, for example—the radiologist will call the clinician, Dr. Schuster said, in addition to filing the computerized results.

The system is structured so that if the ordering clinician does not call up the report within 2 weeks, the computer sends it automatically to the clinician’s supervisor. If the supervisor doesn’t read it, it can be forwarded to the hospital’s quality management (QM) team.

In Asheville, the quality management team monitors how well the hospital is doing with “code 2” alerts—codes that notify clinicians of a patient’s malignancy or possible malignancy. The team checks on which alerts have been acted upon and which have not.

“About 6 months ago, before the system went fully into operation, the QM people said about half of the No. 2s had not been acted upon 2 weeks to a month later,” Dr. Schuster said. “By February 2000, that figure had dropped to 10%.”

Why is there any delay at all? Dr. Schuster said that a physician might wait until a patient’s next appointment to deliver test results. “QM would call to nudge the clinician. Now, the nudge is more often delivered by computer,” he said.

The system has not required extra hardware to get up and running, Dr. Schuster said. It was set up using information architecture present at every VA hospital (Veterans Health Information System and Technology Architecture). It uses Compaq PCs and the Virtual Memory System operating system with applications written in the Massachusetts General Hospital Utility Multi-Programming System (MUMPS) language.