Improve Clinical Communication

June 1, 2009

A university medical center implements a new communications system for rapid delivery of critical information.

Virginia Commonwealth University Medical Center (VCU Medical Center) operates more than 200 specialty areas. The center’s level 1 trauma center has 779 beds and performs as many as 340,000 procedures annually, ranging from plain film radiography to CT and complex interventional procedures.

A university medical center implements a new communications system for rapid delivery of critical information.

Virginia Commonwealth University Medical Center (VCU Medical Center) operates more than 200 specialty areas. The center’s level 1 trauma center has 779 beds and performs as many as 340,000 procedures annually, ranging from plain film radiography to CT and complex interventional procedures.

With the majority of cases, patient exams are processed and care is administered in a timely manner. With a small percentage of the ordered procedures (less than 3 percent), however, communicating life-threatening findings to ordering clinicians is necessary. The challenge is to deliver these results to the correct ordering clinician within the agreed upon time, a minimum of 95 percent of the time without wasting radiologists’ resources.

In the event a patient’s test result comes back with an identified critical finding, the patient’s information should be handled in a certain way to ensure fail-proof accuracy and timeliness of the critical results delivery, as well as proper documentation for auditing and quality-management purposes.

A number of regulatory and accrediting bodies require the reporting of critical results on a timely basis. The Clinical Laboratory Improvement Amendments (CLIA) of 1988 requires that critical results be reported immediately. The College of American Pathologists (CAP) has identified reporting of critical results as a National Laboratory patient safety goal. The Joint Commission requires that all critical results be reported to “the responsible, licensed caregiver” within time frames established by the medical center (defined in cooperation with nursing and medical staff).

In addition to timely reporting, the Joint Commission and CAP require that when critical results are communicated verbally, they be written down and read back to ensure that information has been transmitted accurately.

By automating, much of the daunting manual hindrances that used to be a part of the process were removed.

Before April 2008, if VCU Medical Center identified a critical result or needed to report on a critical test, the radiologist would have to make a phone call or page the patient’s treating doctor (ordering clinician) and wait for a response. Oftentimes, the radiologist did not have the correct phone number or in some instances may have identified the incorrect ordering clinician. The process was inefficient and difficult to track manually, not to mention a time burden on the radiologist. It was inflexible and proved to be only 49 percent effective for message delivery.

Communicating life-threatening patient findings from the time they are identified back to the patient’s doctor is a high priority, and VCU was challenged with better managing workflow associated with critical test results communication. The goal was to increase workflow and communication efficiency, in addition to improving patient care.

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VCU Medical Center automated the communication process for handling critical test results once they are identified in the radiology department in April 2008. The primary goals were: to create a process that communicated results within 60 minutes of dictation 95 percent of the time (actual performance since April 2008 is within 13 minutes, and better than 99 percent of the time); to create an auditable process; to remove radiologists from the clerical portions of the process, freeing them up to dictate more reports; and to create a process that is duplicatable across service lines, from radiology to cardiology, pathology and the vascular lab.

Selecting a Solution

The center wanted a communications system that would work with its speech-recognition solution (PowerScribe for Radiology, from Nuance), and knew that if radiologists could start the necessary communication workflow at the time they were dictating and documenting their reports, they would be more apt to embrace the solution rather than learn and adapt to a non-integrated system.

After conducting a market-product analysis, staff learned about Veriphy, also from Nuance, and added the solution to the information flow process without disrupting the workflow of radiologists, while at the same time meeting the information needs of ordering clinicians.

As Veriphy is not plug-and-play, the process that organizations go through during deployment is critical to its success. The medical center needed to identify and contact all ordering clinicians — virtually anyone ordering exams through the center. Obtained was contact information, as well as their preferred method for receiving notification of patients’ critical results (e.g., pager, cell phone, text, e-mail or fax).

Many of the ordering clinicians gave pager and fax numbers, along with an e-mail address. Some, however, preferred the OR phone as a contact. Regardless, the main objective of this process was to ensure that the center had the most accurate information regarding doctors’ preferences for how the new communications system should contact them.

Within the information populating the Veriphy system, staff also needed to better classify what a critical finding was. Status categories were created for orders ranging from “routine” and “urgent, not life” to “life-threatening.” Life-threatening was defined to indicate that if the finding was not communicated and treatment was not begun immediately, it could result in a patient’s death.

Communicating life-threatening patient findings from the time they are identified back to the patient’s doctor is clearly a high priority, and VCU was challenged with how to better manage workflow associated with critical test results communication.

Originally, there were 32 different clinical information system options for how an exam could be ordered. That number has been reduced to five for improving communication, comprehension and clarity. The radiologist has a similarly streamlined list of just seven categories in which exams can be reported. As an example, “potentially concerning” means that the ordering clinician must be notified of the finding within 12 hours, whereas life-threatening findings must be communicated within 60 minutes.

As a medical center with 600 attending physicians, nearly 650 resident physicians and several hundred physician extenders all ordering radiological procedures, the determination needed to be made whether to spend the time educating the medical staff on the difference between critical tests versus critical results.

In order to avoid becoming prescriptive with critical tests, the center settled on the term life-threatening. This leaves it up to the ordering clinician to determine the order status of a radiological procedure. Within the radiology department, the Massachusetts Coalition of Findings is used to report these findings as life-threatening regardless of how the radiological procedure is ordered.

There was a fear that life-threatening would be overused, but that has not been the case. Approximately 1,200 radiological procedures are performed each day, and only 15 are ordered as life-threatening. Veriphy enabled the staff to convert its workflow from a manual process to better than 99 percent automated without the need for human intervention.

While we did have 32 different clinical information system options for how an exam could be ordered, we have now reduced that down to five to improve communication, comprehension and clarity.

Veriphy is now being used as a general communication tool between ordering clinicians and radiologists for findings the radiologist may deem significant or potentially concerning but not life-threatening. An ED recall of findings may also be indicated, meaning that the radiology attending disagrees with the interpretation of the radiology resident assigned to the emergency department.

Today, VCU Medical Center is averaging 13 minutes from the time a radiologist interprets the test results to the time that the ordering clinician picks up the notification. Of the 4,039 life-threatening messages that have been sent to ordering clinicians, 3,998 or 98.98 percent, have been within compliance.

Communication Automation

Bringing automation to the way radiologists and ordering clinicians communicate patient information, especially high-priority patient information, has been a success at VCU Medical Center. By automating, much of the daunting manual hindrances that used to be a part of the process were removed.

While automation is relied on to push information and document the exchange, there is still a human aspect involved. Caregivers retain the option to communicate via phone or in-person, and if the Veriphy system has a message that goes unchecked, it integrates human interaction to ensure the right person receives the information.

Today, 34 of the center’s 36 radiologists fully support the automated system. While the remaining two feel the system reduces collaboration between radiologists and ordering clinicians, this has been addressed by allowing in-person or phone conversations that later can be documented within the system. On the ordering clinician side, feedback suggests 85 percent of clinicians are fully satisfied with the system, with the remaining 15 percent reporting they wish the system better fit the way they practice.

Future plans at the center are to replicate the process enterprise-wide within the pathology department, cardiology and vascular lab.

Ron Miller is director, radiology, at VCU Medical Center in Richmond, Va. Contact him at [email protected]

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