July 2014

Tracking Incidental Findings
By Bart Daugherty and Reece Ewton, MBA
Radiology Today
Vol. 15 No. 7 P. 6

Lung cancer is the leading cause of cancer deaths in the United States and has a particularly poor prognosis if not diagnosed early. Prompt follow-up on incidental findings from CT scans ordered for other reasons may find more cancers earlier, but a study published in the April issue of the Journal of the American College of Radiology (2014;11(4):378-383) reported that while incidental pulmonary nodules detected on CT pulmonary angiography are common, frequently there is not appropriate follow-up.

The study authors reviewed 1,000 CT pulmonary angiographic studies ordered in the emergency department to determine the presence of an incidental pulmonary nodule. They found that approximately 10% of studies showed incidental pulmonary nodules requiring follow-up. However, follow-up was poor overall, occurring only 29% of the time, and that number dropped to zero when the nodules were mentioned only in the findings section of reports.

This type of oversight prompted the Hospital Corporation of America (HCA) to conduct a pilot program using an electronic system that automates and manages clinician notification of incidental findings. The use case has proven so successful, including saving several lives, that HCA is rolling out the program to more of its hospitals and applying the technology to additional areas, including gastroenterology and cardiology.

Failure to Communicate
Winning the battle against cancer depends both on early detection and taking appropriate and timely action based on clinical results. The timely reporting of these findings to referring clinicians specifically is recognized by the ACR, which updates guidelines for radiologists. The most recent practice guidelines advise that effective communication of findings should do the following:

• Be tailored to satisfy the need for timeliness.

• Encourage physician communication.

• Minimize the risk of communication errors.

Despite the need and emphasis on closing the communication gap, most radiology staff find it difficult to keep community practices informed of significant and critical test results in a timely manner. A study in the Journal of General Internal Medicine (2012;27(10):1334-1348) reported that, in a systematic review of studies, physicians failed to follow up on as many as 36% of radiology reports. The problem is due in part to the sheer volume of exams being ordered across all modalities. According to a 2004 study, the typical primary care physician reports receives 40 radiology reports, and 12 pathology reports per week (Ann Fam Med. 2004;2:327-332).

Already overwhelmed by the number of test results, it is no surprise that clinicians may overlook incidental findings. These abnormal incidental findings, which show up in an estimated one-third of CT scans, may or may not be clinically significant, but they require a considerable amount of time and money for follow-up.

The growing number of imaging techniques has led to an increase in the number of incidental findings. Many of those findings are overlooked because they are buried in the radiology report or ignored since they are unrelated to the condition being treated. Missed and delayed communications of abnormal radiology results are associated with substantial disability and medical costs and are a frequent cause for malpractice claims.

While the HCA has a process in place to address communicating test results, incidental findings that may require separate follow-up often were buried in exam report other indications. For example, if a clinician orders a test for pneumonia and the patient tests positive, the critical result would be immediately communicated so treatment could be initiated. The presence of a lung cancer node, which could be clinically significant but is categorized as an incidental finding in a scan for pneumonia, easily could be overlooked in this case.

Incidental Finding Initiative
Concerned that clinicians may not note these incidental findings, the HCA undertook an initiative using nurse navigators to manually review case files to follow up on incidental findings. The time-consuming manual process resulted in backlogs of as much as six to nine months to review the numerous radiology reports. Coping with this volume threatened to undermine the project’s goal, which was shorter time from diagnosis to treatment.

The HCA initially used a manual process because computers typically are ineffective for uncovering key information when it is presented within unstructured data, which includes radiology reports. Experts estimate that up to 80% of all health care information is contained in an unstructured format. The majority of diagnostic, therapeutic, and ongoing assessment decisions are unstructured, which is problematic since few technology solutions can accurately detect and extract key information.

To achieve their goal of tracking down 100% of cancer notations contained in the incidental findings of radiology reports, the HCA chose the Notifi communication platform to streamline the notification process and take advantage of workflow efficiencies. Notifi is an intelligent health care communication platform from HIT Application Solutions that can locate and extract information within unstructured data reports. With the HCA’s new process, as soon as a report is signed, an incidental indication automatically is flagged for follow-up by a nurse or other practitioner.

The HCA was able to reassign its transcription group, which had 20 years of valuable experience, to the project. Working closely with nurse navigators, they “trained” the system to recognize the difference between valid and invalid incidental findings. It took just four months for the HCA to launch the system, although the company continues to refine the system and add other integrations.

As part of the process, the HCA team reviewed past tests, moving several patients back into the system to be tracked and watched based on incidental findings. During this process, three patients were identified early enough to effectively treat their lung cancer.

The system streamlines clinical workflows either by automatically posting incidental findings to a worklist, where they can be addressed by a nurse navigator, or by communicating the findings to the ordering physician with a request for the course of action. The system then can track the status of these clinical decisions, providing an appropriate audit trail for the originating radiologist or imaging center.

This type of technology can improve radiologist productivity by making it easier to convey findings to clinicians who then can expedite patient care. It also ensures that the recommended studies are performed, generating significant additional revenue for the hospital or imaging center. Most importantly, it improves patient care by ensuring that incidental findings, when warranted, are delivered quickly and efficiently and not lost in a busy enterprise.

Another factor for hospitals, imaging centers, and other health care organizations is the problem of no shows for scheduled appointments. Missed appointments not only lower operating margins but also can delay or compromise treatment. An appointment reminder system within Notifi generates time-sensitive communications to patients and their caregivers. Since an organization controls it, staff can customize messages and alter dates and times to accommodate changing schedules.

The HCA is committed to direct communication with patients when there is bad news to convey. In these situations, the technology can automatically send reminders to nurse navigators to personally contact an individual while ensuring that all relevant information from various departments is readily available.

Hospitals can set up automated reminders across departments to streamline communications. The system automates the notification process and supports telephone-based calling as well as text message and e-mailing. Departments can create a template for each modality or procedure type that determines the form of the message and its content, frequency, and escalation process. In turn, patients can confirm appointments or reschedule, receive driving directions, or request to speak with a staff member.

Conveying Information       
The HCA has found that its automated notification system melds technology and human capital to help predict disease states by pulling information from multiple sources and analyzing it for relevancy. Improved clinical communication of that information can help in the early detection and management of lung cancer. The HCA is using its automated communications system both to identify incidental findings and ensure the delivery of results to busy clinicians and nurse navigators in a timely manner.

— Bart Daugherty is director of application services for the Hospital Corporation of America.

— Reece Ewton, MBA, is a senior project manager for HIT Application Solutions.