Oftentimes, clinicians order an imaging exam but fail to close the loop to ensure that the test is actually scheduled. In some cases, this could expose patients to delayed diagnosis, unnecessary radiation and potential medical errors.
Wanting to better grasp this rarely researched phenomenon, Brigham and Women’s Hospital experts attempted to quantify the number of unscheduled exams that may have slipped through cracks at the Harvard-affiliated institution. Radiologist Ronilda Lacson, PhD, MD, determined that about 7% of exams remained unscheduled in the electronic health record at least one month after the original order date—33,546 tests total.
Clinicians failed to follow through for various reasons, according to the analysis, published Jan. 16 in the Journal of the American College of Radiology. It could have been a duplicate order, or a non-urgent follow-up within one year, for instance. But with radiologists conducting roughly 300 million imaging exams each year in outpatient settings, there could potentially be millions of such exams that are falling by the wayside across the U.S.
“The existence of clinically unnecessary active orders (not canceled or expired) in the EHR may expose patients to unnecessary or duplicate examinations if inadvertently scheduled,” wrote Lacson and colleagues. “Thus, addressing unscheduled radiology orders in the EHR represents a major opportunity for diagnostic process improvement to reduce medical errors.”
To reach their conclusions, the team analyzed nearly 495,000 radiologic exam orders made during a 10-month period ending in October 2016. Those stretched across seven different modalities: CT, MRI, both regular and obstetric ultrasound, bone densitometry, mammography and fluoroscopy. At the Brigham, once a clinician or their proxy places an order, they then must schedule an exam at one of any radiology facilities within the network.
Reviewers deemed tests “unscheduled” if an appointment still had not been slated by Dec. 1, 2016, at least one month from the date the order was placed. Reviewers then sorted through a sample of 700 of these unscheduled exams to gauge clinical appropriateness.
Of that sample, reviewers deemed between 21% and 87% of exams were clinically necessary across all seven modalities. The majority of unscheduled orders were clinically necessary, except in CT, obstetric ultrasound and fluoroscopy. Most of those orders were for follow-up imaging, the team noted, and the number of clinically necessary yet unscheduled tests in bone densitometry was “significantly higher” (87%) when compared to other tests.
Across most modalities, “symptom resolved” was the most common reason for unscheduled orders appearing to be clinically unnecessary (i.e., a woman who gave birth and no longer needed an ultrasound). In CT and MRI, “examinations performed elsewhere” was the most frequent cause for failing to schedule, the team found.
There are numerous opportunities for radiologists to intervene in a “strategic manner” to address this problem, Lacson and colleagues explained. Possible solutions include:
- Duplicate decision support to alert providers in real time of similar orders that may have already been executed.
- Intuitive and efficient workflows to ensure that providers cancel any orders when they’re no longer necessary.
- Computerized tracking systems that can prod providers to remind their patients to follow through.
- Addressing known factors that enhance patients’ follow up adherence on radiologic exam orders.
- Looking outward to keep an eye on radiography exams that may have been conducted outside of the system.
Brigham and Women’s itself has launched a multifaceted intervention to begin eradicating the problem. While the study’s results may not be directly generalized across all other healthcare institutions, it’s safe to say this problem is much more widespread that just one Boston-based hospital, the analysis concluded.
“The potential quality and safety implications and the extensiveness of the improvement opportunity across all referring departments and clinics at our institution likely exists at many other institutions,” Lacson and colleagues wrote. “Clearly, more work needs to be done in addressing unscheduled diagnostic radiologic examination orders to ensure that diagnostic evaluation is completed in a timely manner to promote patient safety,” they added later.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.