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What Makes Emergency Docs Happy with Radiology? Accuracy is #1

| March 15, 2014

Speed is of the essence in emergency departments (EDs). But when it comes to radiology, doctors put quality first.

Radisphere recently conducted focus groups with ED providers representing large practices at facilities from three U.S. health systems and found that clinical accuracy ranks No. 1, followed by speed and high-value reports (see chart).

Interpretive errors loom large in the ED, as they can seriously affect patient experience, health outcomes and costs. Errors can result in incorrect or delayed treatment of conditions such as stroke that require immediate action.

Speed and value

After quality, ED physicians care about speed. But rather than focus on average time for radiologist interpretations—say, the radiologist averages 30 minute turnaround times (TAT)—providers want the report to arrive when they need it to treat the patient. This is a subtle but significant difference for hospitals and health systems, which often measure TATs by uniform benchmarks and averages.  Each case type, priority, and facility may have different TAT requirements, suggesting customized solutions are in order.

Report value is the third biggest driver of ED physician satisfaction. Valuable radiology reports are not only accurate (getting the answer right), but also address the clinical question asked by the ordering clinician (answering the right question). Valuable reports are critical to guiding the ED physician in providing the best treatment for the patient in a timely manner. Consistently delivering valuable radiology reports also helps radiologists build trust among the medical staff and become more tightly integrated members of the care team.

At times, however, the ED physician receives reports from radiologists that are equivocal or fail to fully address the clinical question. For example, the ED physician may get a report of diverticulitis, but it does not specify whether there is simply a pericolonic inflammatory process or a pericolonic abscess, an important differentiation for deciding medical (non-operative) or surgical treatment.

Better communication is key 

The focus group results strongly indicate a need for improved communication between ED providers and radiologists. Better communication can boost accuracy, speed and the value of reports all at once.

For example, when radiologists have access to the comprehensive patient record and ordering provider notes (how the patient was injured, location of pain, specific concerns, etc.), a high percentage of the time they will return valuable reports that address the reason for the image. If the information is not available, ambiguous or incomplete, however, the radiologist may not address the reason for the exam or provide a definitive interpretation that is valuable to the ordering clinician.

In many cases, this is due to patients visiting multiple facilities, or lack of integration between electronic health records and radiology workflow technology. At times, overcrowded EDs and protocol-triggered ordering can cause the exam to be ambiguous or blank, leaving the radiologist in the dark.

“When the ordering physician writes ‘fall,’ the radiologist seldom knows whether it was from a standing position or out of a 10th-story window,” notes Dr. David S. Hirschorn, MD, in a Medscape article titled “Radiology and the Emergency Department—We Should Talk!”

ED physicians are particularly concerned about being notified of critical findings, such as a brain hemorrhage, that require urgent action. The Joint Commission requires hospitals to document such communication as part of its regulation of hospital accreditation.


An advisory role for radiologists

As a route to better communication and rapport, ED providers are looking for more interaction with radiologists they trust. This puts radiologists in the position of advisors as opposed to mere order takers.

As advisors, radiologists can not only guide ED providers during diagnosis and treatment planning, but also before scans are ordered. This helps optimize the use of appropriate imaging for health systems, which is critical in the transition to value-based care. For example, radiologist support can reduce overutilization of high-tech imaging for conditions like lower back pain (which, as discussed in a previous blog post, often leads to unnecessary scans, misdiagnosis and invasive surgery).

To paraphrase an ED physician from one of the Radisphere focus groups, “Improved communication between Radiologists and ED physicians to discuss clinical issues will pay dividends in improving patient care and reducing unnecessary imaging.”

Enabling an expanded role

Because of the urgency of cases in the ED, hospitals and health systems have a couple of options to improve communication between ordering clinicians and radiologists: 1) station a radiologist in the ED 2) leverage technology to improve information flow and accessibility.

The first option has major challenges, including high cost and reduced productivity for radiologists due to interruptions. The ED’s peak hours are often in the evening and overnight hours, which do not match well with traditional radiologist on-site hours or lifestyle preferences.

The second option is more attractive, and goes beyond traditional concepts of software-based clinical decision support that have been gaining momentum in the industry (as discussed in a recent Washington University School of Medicine study) to combine technology-enabled decision support with more meaningful, direct collaboration tools between ED physicians and radiologists. Communication can be facilitated through dedicated phone lines, instant messaging, and virtual conferencing.

This comprehensive approach not only creates the desired accessibility of radiologists in the ED, but enables tighter integration of patient information and promotes adherence to standards, allowing radiologists to guide the delivery of high value patient care.

Radisphere conducted the focus groups between November 2013 and January 2014 with ED providers  representing large practices at three health systems: Adventist Health Central Valley Network in California, Adventist Healthcare in Maryland, and NCH Healthcare System in Florida.

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