Support Tests.

Bruno, Michael mbruno at HMC.PSU.EDU
Wed Jan 27 15:46:18 UTC 2016


We in Radiology do still expect to receive a lot of phone calls from referring physicians to discuss cases – I take several such calls a day.  The kind of two-way communication that takes place in those phone calls frequently leads to greater diagnostic accuracy than would result from just reading the cases blindly (as we often do when the clinical history is something like, “Abdominal pain 789.00.”)  I am skeptical that some sort of text messaging within the EMR would be a good substitute for the kind of give and take one can get in an actual conversation over the phone (or in person), despite the increased perception of efficiency that text-messaging offers.

Also, while the bygone practice of individual physicians coming down to the radiology department once or several times each day to review each of their cases with a radiologist may be impractically inefficient in the modern digital era—now that it is no longer needed to get a result or view an image—the time-tested practice of holding regularly scheduled interdisciplinary diagnostic conferences, including multiple physicians and subspecialty-qualified radiologists to discuss challenging cases, whether they are held in the radiology department or elsewhere, is still both a viable and highly desirable option in my opinion.  At our own institution (Penn State) these sorts of conferences are scheduled weekly (or even more frequently) for each medical and surgical subspecialty, and in these conferences we radiologists routinely meet with groups of clinicians to go over a preselected list of cases in person.  They conferences make up a significant fraction of each radiologists’ workload.  Sometimes the pathologists attend as well.  We’ve even held such conferences on an ad-hoc basis at short notice to discuss individual cases and guide workup decisions.  In our department we have specialized private meeting rooms constructed within our reading areas, equipped with gigantic digital viewing screens, which we had built for just this purpose.

Despite the increasing drive for efficiency in RVU production, I sincerely believe that the regularly scheduled interdisciplinary conference is still a viable model, unchanged by our migration to the digital age of widespread, instantaneous image distribution.  It is non-interruptive and un-rushed, and thus avoids the risks of errors related to interruption and rushing, and it brings together experts from across multiple disciplines to discuss ALL of the diagnostic information available in an interactive way that improves the performance of all involved.  It’s all that’s left of the old vestige of the bygone era of past decades where we had the luxury of discussion of the majority of our cases each day with the referring clinicians.  And yes, Bill, I am still a bit nostalgic for those days!

All the best,

[Full Signature]
Michael A. Bruno, M.S., M.D., F.A.C.R.
Professor of Radiology & Medicine
Vice Chair for Quality & Patient Safety
Chief, Division of Emergency Radiology
Penn State Milton S. Hershey Medical Center
• (717) 531-8703|  •mbruno at hmc.psu.edu<mailto:mbruno at hmc.psu.edu> | 6717.531.5596
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From: Follansbee, William [mailto:follansbeewp at UPMC.EDU]
Sent: Tuesday, January 26, 2016 3:21 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Support Tests.

Very interesting suggestion, if the EMRs can handle that type of communication.

From: Andrew Olson [mailto:olso5714 at umn.edu]
Sent: Tuesday, January 26, 2016 1:49 PM
To: Society to Improve Diagnosis in Medicine; Follansbee, William
Subject: Re: [IMPROVEDX] Support Tests.

I think there are clear technological solutions that would allow for interaction between clinical and perceptual teams that don't involve the proverbial trip to a different part of the hospital, thereby modernizing a historical activity that was both inefficient and important.   It would be relatively easy to have a "click to chat with the radiologist" box in an EMR.

On Tue, Jan 26, 2016 at 11:53 AM, Follansbee, William <follansbeewp at upmc.edu<mailto:follansbeewp at upmc.edu>> wrote:
I trained in those days as well, with similar experiences. Your question is an important one and the answer is simple. There are no films anymore. Everything is now digital and is available at the point of care. The workflow no longer involves a trip to the radiology department. Those days are gone forever. The challenge is how can those interactions be reproduced in today’s work flow? That is a difficult challenge. The only way that I could envision that happening would be for radiologists to leave their department and make rounds, going to different inpatient services and making radiology rounds with them on site. This, of course, would be a major time commitment for the radiologists and for that reason might not be possible. Short of that, however, it is difficult imagine how to recreate it.
We also should not get too caught up in nostalgia. These interactions were quite valuable but they were also a highly inefficient use of time. Clinical teams would trek together to the radiology department, stand for what seemed like forever at the file room while clerks sorted through mountains of films trying to find the ones that were needed, which not infrequently weren’t even in the department, before those valuable interactions with the radiologists could occur. That is why when digital imaging came along, point of care availability of the images was immediately adopted.
An important issue but also a difficult challenge.

William P. Follansbee, M.D., FACC, FACP, FASNC, FAHA
The Master Clinician Professor of Cardiovascular Medicine
Director, The UPMC Clinical Center for Medical Decision Making
Suite A429 UPMC Presbyterian
200 Lothrop Street
Pittsburgh, PA 15213
Phone: 412-647-3437<tel:412-647-3437>
Fax: 412-647-3873<tel:412-647-3873>
Email: follansbeewp at upmc.edu<mailto:follansbeewp at upmc.edu>


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From: Bob Latino [mailto:blatino at RELIABILITY.COM<mailto:blatino at RELIABILITY.COM>]
Sent: Tuesday, January 26, 2016 11:55 AM

To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Support Tests.

If this practice was so effective in the 70's and 80's, why did it fade away?
Why aren't such proven best practices maintained and sustained?

Robert J. Latino, CEO
Reliability Center, Inc.
1.800.457.0645<tel:1.800.457.0645>
blatino at reliability.com<mailto:blatino at reliability.com>
www.reliability.com<http://www.reliability.com>

From: Albert Wu [mailto:awu at JHU.EDU]
Sent: Tuesday, January 26, 2016 11:05 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Support Tests.

I recall doing precisely this while a med student and resident at New York Hospital, and Mt Sinai in NYC in the mid 80s
albert

From: Alan Morris <Alan.Morris at IMAIL.ORG<mailto:Alan.Morris at IMAIL.ORG>>
Reply-To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Alan Morris <Alan.Morris at IMAIL.ORG<mailto:Alan.Morris at IMAIL.ORG>>
Date: Tuesday, January 26, 2016 at 10:19 AM
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: Re: [IMPROVEDX] Support Tests.

You may be interested to know that in the 1979s and 1980s we made daily rounds with the radiologist and interpreted the films together.  This was unequivocally produced remarkable returns and was a good investment of time in a high-tech intensive care unit.  Better communication is always desirable.  I am reminded of a quote from George Bernard Shaw:
“The single biggest problem in communication is the illusion that it has taken place."

Alan H. Morris, M.D.
Professor of Medicine
Adjunct Prof. of Medical Informatics
University of Utah

Medical Director, Urban Central Region Pulmonary Function Laboratories
Pulmonary/Critical Care Division
Sorenson Heart & Lung Center - 6th Floor
Intermountain Medical Center
5121 South Cottonwood Street
Murray, Utah  84157-7000, USA

Office Phone: 801-507-4603<tel:801-507-4603>
Mobile Phone: 801-718-1283<tel:801-718-1283>


From: Leonard Berlin <lberlin at LIVE.COM<mailto:lberlin at LIVE.COM>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Leonard Berlin <lberlin at LIVE.COM<mailto:lberlin at LIVE.COM>>
Date: Tuesday, January 26, 2016 at 05:56
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: Re: [IMPROVEDX] Support Tests.

Without any doubt whatsoever, the radiology literature is replete  in confirming that the more clinical information that is provided to radiologists.  the more accurate will be their reports.

Will clinical info on occasion bias the radiologist?  Yes, but very rarely.  Any potential "harm" of providing  the radiologist with clinical info is far, far,  outweighed by the benefit.

Lenny Berlin, MD
Professor of Radiology,
Rush University and
Uiv. Ill, Chicago


> Date: Tue, 26 Jan 2016 04:30:40 +0000
> From: Joe.Grubenhoff at CHILDRENSCOLORADO.ORG<mailto:Joe.Grubenhoff at CHILDRENSCOLORADO.ORG>
> Subject: Re: [IMPROVEDX] Support Tests.
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>
> Is there not data that indicated that giving more, not less, information to a radiologist in a requisition improves the accuracy and clinical utility of the interpretation? As an PEM physician I teach the residents that our radiology colleagues are consultants just like a cardiologist. Call them, ask what the most reliable study is for the clinical question. Saves time and money by avoiding unnecessary or inappropriate exams that don't resolve or often muddy the clinical picture.
>
> Sent from Skynet
>
> > On Jan 25, 2016, at 21:12, Elias Peter <pheski69 at GMAIL.COM<mailto:pheski69 at GMAIL.COM>> wrote:
> >
> > I addressed my concerns to the radiologists and pathologists, not the hospital. They agreed that changes were needed, did not always agree on what changes were needed, and most were willing to try things to see what did and didn’t help.
> >
> > The administrative structure was not impressed with the clinical request that we expend some of the institutions resources (time, IT work, communication system to discuss what we were doing) and the requests eventually died out.
> >
> > I understand the concern that clinical information might bias a radiologist’s reading. The same thing could be said about the patient history biasing my exam, test ordering, assessment or plan. The purpose of information is to point us in some direction. The solution to this is NOT to hide clinical information from the radiologist/pathologist (or the patient) but to make as much information available to as many people on the team as possible.
> >
> > Peter Elias
> >
> >
> >> On 2016.01.25, at 9:08 PM, Stefanie Lee <stefanieylee at GMAIL.COM<mailto:stefanieylee at GMAIL.COM>> wrote:
> >>
> >> Part of the issue is framing (addressed in the recent IOM report) -
> >> the view of the diagnostic specialties as provider of test results,
> >> which are then used by the primary physician to diagnose the patient -
> >> versus the pathologist or radiologist as being integrated into the
> >> ongoing discussion and diagnostic process.
> >>
> >> Communication is essential to safe patient care. As more than one
> >> scenario can have the same imaging appearance, it is the clinical
> >> information that allows the radiologist to form an educated opinion as
> >> to what the significance of the finding is (and avoid the dreaded
> >> 'cannot exclude'!)
> >>
> >> Rim-enhancing collection with gas bubbles in the surgical bed - an
> >> abscess that needs to be drained, right? Not if Surgicel had been used
> >> during the operation (a hemostatic agent that has a very similar
> >> imaging appearance).
> >>
> >> Given a CT or MRI which may have numerous abnormal findings in its
> >> hundreds/thousands of images, the diagnostic process of putting all
> >> the findings together to form an interpretation / hypothesis about
> >> what is going on is not really all that different from other fields in
> >> medicine.
> >>
> >> Sometimes referring physicians are concerned about 'biasing' the
> >> radiologist with clinical information, but providing less information
> >> is unlikely to help improve accuracy - better communication will. If
> >> anything in the report doesn't fit - pick up the phone or send an
> >> email/fax for a second look!
> >>
> >> As another example, consolidation on a chest radiograph is a
> >> nonspecific finding that very frequently represents pneumonia and is
> >> reported as such, but if this is a chronic process (especially if the
> >> patient has weight loss without signs of infection), it could very
> >> well be cancer.
> >>
> >> Agree that providing patients access to test reports will help reduce
> >> findings falling through the cracks. I read about patient portals on a
> >> regular basis - how commonly are they used today?
> >> http://meetinglibrary.asco.org/content/120470-140
> >>
> >> Another area for improvement is to improve the ease/frequency with
> >> which diagnostic specialists and office-based physicians communicate
> >> with each other (e.g. direct phone lines).
> >>
> >> Multidisciplinary rounds and discussions with referring physicians who
> >> drop by the reading room are very helpful in clearing up diagnostic
> >> conundrums - however, this mostly happens in the hospital setting.
> >>
> >> (cannot tell from Dr. Elias' post if he conveyed his concerns about
> >> the reports to the hospital or spoke with the radiologist directly - I
> >> hope improving communication would be a goal of all involved in
> >> patient care, for many obvious reasons)
> >>
> >>
> >> On 24 January 2016 at 16:55, robert bell
> >> <0000000296e45ec4-dmarc-request at list.improvediagnosis.org<mailto:0000000296e45ec4-dmarc-request at list.improvediagnosis.org>> wrote:
> >>> I have suggested that at the same time, or even before we tackle Errors in
> >>> Diagnosis, we see that all our support diagnostic tests (Lab, X-ray, etc.)
> >>> are in good order so as to help make the correct diagnoses more often.
> >>


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