November 20, 2006
Test Results – Closing the Communication Loop
Adding automation can cut down your staff's frequent hunts for referring physicians—and document that they receive a critical report about a patient's exam.
It could be a routine CT scan that shows a suspicious-looking lesion or a blood test suggesting a potentially lethal infection. The radiologist—or other reporting clinician—has the seemingly simple job of communicating that critical finding to the referring physician, and ultimately, back to the patient. Yet, there are too many stories about the tragic results of not closing that critical loop. Such communication problems represent a serious threat to patient safety, according to the American College of Radiology, the Institute of Medicine, and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Communication problems account for a large number of malpractice claims against radiologists and other physicians. Critical test results involve all diagnostic testing including imaging exams, electrocardiograms, and laboratory studies.
JCAHO, as part of its national Patient Safety Goals issued in 2004, requires that hospitals adopt specific measures to improve communication among radiologists, other reporting clinicians, and test-ordering clinicians.
But that raises the question: What measures?
"Technological innovations have focused on automating patient records and information, images, and voice-recognition dictation. But there hasn't been automation in the process of communication between the radiologist and ordering physician," says Tom White, cofounder and executive vice president of sales and marketing at Vocada, Inc., a Dallas-based company that offers an answer to that communication question.
Needle in Haystack
The challenge with test results is that so many tests are ordered that individual results are vulnerable to systemic errors. A radiologist report can get lost at any step between the imaging center and the referrer. A test result faxed to an office can end up on the wrong desk. A report could be misfiled in a referring physicians' office that doesn't have a test log in place.
Such vulnerability prompted Vocada to develop software-based technology to address this communication problem. The company calls the problem critical test result management. Its solution enables a hospital's management and clinicians to create performance standards for communicating test results, to better monitor performance, and to immediately act on problems that arise.
When facilities establish a results reporting system, they typically develop an essentially manual system, which can be "labor-intensive and prone to errors," according to White. Such processes can have little impact on improving patient safety and outcomes and can decrease staff productivity. In response, Vocada developed a system called Veriphy that uses automation to streamline verified communication of results between referring and reporting physicians. First introduced in 2004, the software-based system is now used by approximately 80 hospitals.
The company describes Veriphy as an enterprisewide solution for an enterprisewide problem. It provides a means for verified communication of critical test results by clinical staff. "The patented system provides a platform that allows communication to be created via voice or text and then sent in an verifiable manner," describes White. "That is, the transmission of the communication by the reporting clinician and its receipt by the ordering clinician is easily verified."
Further, it provides hospital managers the ability to measure the performance of their diagnostic departments and ordering clinicians and compare the results against performance goals. "Veriphy provides a reportable database that customers can use to create metrics and performance improvement reports on how well they're communicating," says White.
Vocada built Veriphy on what it determined were three fundamental principles:
- A system should be institutionally sanctioned and supported, with commitment from management and medical staff leaders. All principals must be committed to their system as a quality-of-care and patient safety issue. Further, they must be committed to overcoming natural resistance and implementation obstacles.
- Outreach to end users is essential and both reporting and ordering clinicians must be actively involved and feel a sense of ownership.
- A process for continuous improvement must be put in place, as a solution must be able to evolve to survive and thrive.
Timely and Verified
Vocada created its solution with several attributes in mind: critical test reporting would reach the ordering clinician in a timely manner, the receipt of such information by the ordering clinician would be automatically verified, and the technology would be active rather than passive. As an active system, it would alert the ordering physician in real time when a report is available and indicate the report's degree of urgency, which helps the physician to determine whether it needs immediate attention.
Further, Vocada wanted a user-friendly, easily deployable system that would require minimal change in behavior for reporting and ordering clinicians, as well as be accessible to all physicians. It also wanted a system that would work the same whether the critical test result comes from radiology, cardiology, or the pathology lab, and enable each diagnostic department to establish its own rules for reporting and message escalation. It also wanted compliance with communication rules and guidelines built into the system.
With all these elements combined, Veriphy couples voice messaging and data technologies to create a verifiable system for communicating test results.
How It Works
On the reporting clinician end, Veriphy is as simple as using a telephone. Essentially, when a radiologist (or other clinician) has to report an urgent finding, he or she needs to place only one call—even though a referring physician often proves hard to reach. The reporting physician creates a voice message by calling an assigned Veriphy phone number (if using the Veriphy Desktop option, they use a microphone on a PC), input the ordering physician's code, and communicate the results. The system sends instant notifications to the ordering clinician via pager, cell phone, fax, and e-mail.
Tracking the Referrer
The ordering clinician receives an alert that a critical test result message is pending. The physician then dials a toll-free number, enters a secure code, and listens to the message. Veriphy will then alert the reporting clinician that the message has been retrieved and when. If a message has not been retrieved within a preset time frame, Veriphy will transmit escalation notifications to both the reporting and ordering clinicians.
"The intent is that the ordering physician can't get away from the message," says Rick McManemon, MHA, RT(R), administrative director of imaging services at Denton (Tex.) Regional Medical Center. "They couldn't ignore it if they wanted to, not that any physician would ever want to ignore a message. But if something pulled them away, Veriphy would still keep chasing them."
Veriphy provides a more productive process, agrees Jean Plummer, manager of radiology informatics at Baylor University Medical Center in Dallas, which is part of the large-scale Baylor Health Care System that serves the Dallas/Fort Worth area. "Our radiologists tell me that, in the past, if they had a critical finding that they needed to report to a referring physician, they had to access a phone directory, look up a phone number, call the office, go through the phone tree, and maybe have someone track down the physician," she says. "Maybe about 15 or 20 minutes later, they would finally get to talk to a referring physician. It was very labor-intensive."
Baylor introduced Veriphy in a four-month pilot program that started in January 2005, involving a select number of referring physicians and all its radiologists. The pilot was a success and the health system officially implemented Veriphy in August 2005. "Since that time, Baylor Health Care System has chosen to deploy it within the radiology departments of its seven other hospitals," says Plummer, adding that the health system as a whole performs more than 900,000 exams per year.
"At the Medical Center alone, we perform 375,000 [exams] a year," says Plummer. "We have 83 radiology residents and fellows who send critical test result messages. We're doing hundreds of exams every day, so it is a valuable tool. It takes only 30 seconds to send a message as opposed to 20 minutes to track someone down, which is a significant impact on workflow."
Barbara Corning-Davis, enterprise clinical imaging manager at North Shore Medical Center/Salem Hospital in Salem, Mass., where Veriphy was implemented in May, says the system provides oversight. "It makes sure that the results that get sent to critical care areas are acted upon," she says. "It gives you a focus on the small percentage of critical values that need to be followed up on and that can fall through the cracks. It has really illuminated the problem areas, enabling us to identify them and correct them."
Simplifying the Process
Since Veriphy is a hosted solution, it requires no new hardware or software investments. When a hospital subscribes to the service, the Vocada technical team builds a customer's communications directory or referring physician and then sets up the system for use. The system is easily adaptable to the working preferences of most clinicians. It comes with the Veriphy Desktop, an optional add-on application for reporting clinicians who communicate via a desktop or laptop computer. Veriphy also offers Web-based monitoring of all activity and original messages are archived in a searchable database for 10 years or longer, according to the company. The system also integrates with the hospital's physician directory, allowing for simultaneous updates.
"The technology certainly makes critical result reporting less complex, just because it is an easy system to use and does not normally require any follow-up," says McManemon. White says Vocada's customer base includes all kinds of hospitals, from large academic institutions to small community facilities. "Every hospital that I have been to has a problem," he says. "Communication of critical results is not an easy process."
A Texas Tale
Denton Regional Medical Center, a 184-bed, full-service hospital with 850 employees and 250 physicians, implemented Veriphy two years ago in hopes of improving an inefficient results reporting process. Wanting more timely response to ordering physicians was the main reason Denton implemented Veriphy.
"It allows us to expedite patient care by providing faster results, which assists the ordering physician in treating the patient much faster," says McManemon. "In the case of positive findings, when the patient needs intervention, waiting for a written report is not an option. The system allows us to locate and notify the physician very quickly."
Patient safety would be otherwise compromised, he says. "But if findings are acted upon swiftly, the patient receives faster care, which prevents that patient's condition from becoming worse."
Before implementing Veriphy, Denton employed a manual system that involved staff calling the referring physician's offices. "Often, the physicians weren't available or couldn't be found," explains McManemon. "Now, Veriphy automatically finds the physician and provides the results without our staff or radiologists having to take time away from patient care and other duties. They don't have to waste time on the phone trying to track down a physician."
That's a benefit to the staff, but the one who ultimately benefits the most is the patient, says McManemon. "Our main problem was that we didn't always know what to do when a patient had a procedure and critical values were identified. A patient may have needed care, but it was difficult or impossible to locate the patient's physician. Now, we can notify physicians much more quickly and they, in turn, can provide care much more quickly, which improves outcomes."
– Dan Harvey is a freelance writer based in Wilmington, Del., and a frequent contributor to Radiology Today.