When it comes to electronic communications for radiology, it’s all in the workflow, says Andrew Wells, MD, a radiologist with Hendersonville Radiological Consultants, an eight-partner practice that covers three hospitals in western North Carolina.

“You have to be able to receive information for workflow at the point of doing work, and you need to be able to create an outbound message where you are doing your interpretation—it’s got to be that convenient,” he asserts. “That’s a sticking point for workflow communication.”

Making that happen is a lot more complicated than it may seem, but 220-bed Margaret R. Pardee Memorial Hospital is making progress toward that elusive goal—efficient electronic communications in radiology. Eighteen months ago, the hospital deployed Synapse Communications with Tasks from FUJIFILM Medical Systems U.S.A., Inc., Stamford, Conn., streamlining intra-departmental communications within the hospital’s Synapse PACS environment.

“The communication tool that we have deployed electronically, in Fuji-speak, is called the Task, and it has eliminated the need for a technologist to find a radiologist to read a call report exam,” Wells explains. “We now have an electronic workflow.”

Instead of calling around to find a radiologist to read a stat case, the technologist creates an inbound message that is blasted to all radiologists who are reading, providing patient name, type of study, accession number and an icon that says ready to read call report. All radiologists see that and after they complete their current case, if they see that patient on an unread list, they open the case and read it next.

“I can open a window that completes the inbound message, and I can create an outbound message to the technologist that replies, ‘It’s read, the preliminary is a typed note, please find note and call to doc XY and disposition to patient,” Wells says. “There’s no searching for the radiologist to read the call report, and I don’t have to search for the technologist to accept the message: It’s done, please call the report.”

If a radiologist comes across a study with findings—incidental or otherwise—that a referrer should know about, he or she no longer needs to call the technologist and ask that the results be called to the referrer. He or she can create a call report and force a message to the technologist explaining that the study is a physician-declared call report and must be directly communicated to the physician. “Again, I don’t have to call around to send that message to the technologist,” Wells says.

Managing ED discrepancies

With intra-departmental electronic communications in place, Pardee Hospital is poised to extend similar efficiencies to communications outside of radiology with a new, upcoming version of Synapse Communications currently being tested at Pardee. The process of managing ED discrepancies at Pardee Hospital provides a good, real-world example of the challenges of communications between departments. Effective communications between the ED and the radiology department are critical to patient care and typically require a good deal of human intervention: Notes must be typed by radiologists, phone calls made and technologists engaged to deliver results to the ED.

Radiologists from Wells’ group read ED cases contemporaneously, real-time, inside Synapse PACS. With the implementation of Synapse Communication, the ED physicians—working with Synapse PACS open on their computers—see an icon pop up when a preliminary report is present. “We type ‘negative chest’ or ‘left hip fracture, no dislocation’, and the ED doctors get that electronically,” Wells explains. “When they see that icon, it is the visual ding—you’ve got mail—, without a phone call or piece of paper.”

ED discrepancies occur when the ED physician takes an initial look at, for instance, a radiograph and records a preliminary reading, Wells explains. “They have to tell you ‘negative chest’,” he explains. “If they tell me ‘negative chest’, and I report ‘left lower-lobe pneumonia’, then I know there’s a discrepancy, and I can act to send the next communication back to them.”

Two steps are then performed in the ED discrepancy workflow at Pardee Hospital: The radiologist records a typed note using the phrase “updated preliminary.” That note—identifying left lower-lobe pneumonia—occurs in the same place as the ED physician’s negative. However, best practices suggest acknowledgement of receipt, and currently that requires that either the technologist deliver the printed results to the ED via sneaker-net or the radiologist picks up the phone.

“We are looking to move outside of the department with electronic messaging, which would allow me to respond with the update and send it back to the provider within an ED discrepancy workflow,” Wells says. “They would have an electronic message that is sticky and doesn’t go away until someone accepts or acknowledges it.” With Synapse Communications, an icon pops up, and if the mobile application is enabled, called Pulse, the message can be viewed on a smart phone, tablet or computer.

Another new function will provide ED physicians with the ability to send outbound messages to the radiology department when, for instance, a super-stat head CT or stroke protocol is required.

Outbound, next frontier

After using the updated Synapse Communications software in a test environment, Wells envisions improved communications with all referrers and the potential to improve patient care. “Our next opportunity is to integrate urgent findings and unexpected significant findings electronically to the ED and electronically to non-ED ordering providers,” Wells says. “The goal is to be able to create alerts for referring providers with various time windows that correspond to the urgency of the message.”

A message about an abscess on an abdominal CT might have a four-hour window, for instance, while a non-urgent but significant incidental finding might have a three-day window, not urgent enough to disrupt the referrer on a weekend or contact a covering physician at night for an outpatient exam result. 

“If the ordering provider receives it and acts on it, it closes, and I know it’s closed,” Wells says. “If they don’t accept it, I would then see this had not been closed and has exceeded the four-hours or three-day window, and I can take steps to close the loop. On the other end of the spectrum, you can use it to augment critical test result communication documentation, which we consider a one-hour finding.”

Because voice recognition has not been implemented, critical results must be documented with a radiologist-typed preliminary note, called into the ED and documented again in the report with the name of the person who receives the results. Even with electronic communications to the ED, Wells says that phone calls will continue to be protocol for a critical test result.

“Making a phone call is still good medicine, and we are going to strongly encourage that,” he says. “But if you can have an electronic inbound message and a reminder to make it an automatic outbound just by completing it properly, it’s another safety layer.”

Looking ahead, Wells envisions the tool being used to follow up on incidental findings—for instance, a 2-cm lung mass found on a stone CT—to be make sure they aren’t overlooked. “It is the significant but not urgent finding of the report that can get lost,” he says. “Being able to create an outbound message with a time window that sends an alert if it is not acted on, offers the potential to do that.” The new communications features within Synapse PACS provide the ability to send outbound messages as well as create outbound tasks for the radiologist or the technologist to follow up on a patient in a day, a week, a month or any other appropriate time interval.

The key to success

Hospitals are littered with IT solutions that go unused for one primary reason: They do not take into account the practitioner’s workflow. “I have to be able to receive messages, create messages and create a peer review entry from the place that I am working,” Wells says. “That really revolves around integrating it into the PACS environment so that you don’t have to step into a different application or step out to do it.”

Hendersonville Radiology currently tasks radiologists with presenting peer review documentation for 10 percent of studies interpreted each month. Paper forms are marked to agree or disagree with the interpretation of the prior report. The cases are adjudicated or reviewed by the group and then submitted to ACR RADPEER™. Within Synapse Communications as radiologists are reviewing a study, if they click on the peer review icon, agree is auto-selected, as the vast majority of peer review cases are agrees.

“What we’ve come to recognize,” Wells says, “is it’s all centered around the prior report or the current exam report, so building that communication tool around a report page has been the focus.”

In the short term, the radiologists at Pardee Hospital are enjoying the benefits of fewer intrusions into their workflow. “It’s delightful to stop inbound phone calls that I don’t have to take to notify me that Mrs. X has a chest x-ray, go read the report, or patient waiting on report,” Wells says. “I get it electronically, but all radiologists get it electronically, so it distributes that work across the group that is reading.”

When it is time to send the outbound message saying call report ready, Wells doesn’t have to try and figure out which phone number to call. “It just happens,” he says. “The shift supervisor can see both the inbound and the outbound messages and make sure that they are clearing.”

In the future, Pardee Hospital radiologists look forward to leveraging Synapse Communications to raise the patient-care bar even further by following up on incidental findings. “I look forward to being able to send a non-disruptive message to myself to say, ‘Let’s make sure this patient gets a reminder in 3 months or 6 months to get a follow-up,” Wells says. “I also can send that to the ordering physicians.”