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Accuracy of Information on Imaging Requisitions: Does It Matter?
Accuracy of Information on Imaging Requisitions: Does It Matter? Mervyn D. Cohen, MB, ChB, MD
Imaging requisitions are the major manner in which clinicians communicate to radiologists with regard to imaging studies they are requesting. Errors in the information provided on requisitions may have a deleterious effect on the quality of the imaging reports and services provided by radiologists. The author reviews all of the many problems and errors that can occur on imaging requisitions in addition to inadequate clinical histories. The author then discusses how to identify and resolve these errors. Key Words: Imaging requisition, communication, quality of radiology service J Am Coll Radiol 2007;4:617-621. Copyright © 2007 American College of Radiology
INTRODUCTION In an article published early in 2006, Ruiz and Glazer [1] reviewed in detail a New York Times article about a patient who had to wait several weeks to be informed that the results of a computed tomographic scan for suspected cancer were normal. The study had been interpreted by a radiologist about an hour after it was completed. The authors concluded that there is a need for direct communication between radiologists and patients. Their implication was that the report was sent to the internist, who failed to communicate the results to the patient for several weeks. They failed to consider other causes for the breakdown in communication. Could it have been due to an error on the imaging requisition? Could the wrong internist’s name have been provided and the report sent to the wrong internist? The need to provide high-quality care is intuitively obvious. The ability of current imaging technology to evaluate physiology, anatomy, and pathology is truly amazing. Superb computer technology allows the rapid transfer of images and information. To achieve highquality radiologic service, we cannot rely on our outstanding technology alone. Good bidirectional communication between radiologists and referring physicians remains an essential ingredient for the provision of highquality care. In the high-tech environment, a focus on the basic imaging requisition seems somewhat mundane and redundant. Many would say that the issue has been beaten to death. It does, however, remain an obstacle to Department of Radiology, Riley Children’s Hospital, Indiana University School of Medicine, Indianapolis, Indiana. Corresponding author and reprints: Mervyn D. Cohen, MB, ChB, MD, Riley Hospital for Children, Department of Radiology, 702 Barnhill Drive, Room 1053, Indianapolis, IN 46202; e-mail: [email protected]. © 2007 American College of Radiology 0091-2182/07/$32.00 ● DOI 10.1016/j.jacr.2007.02.003
optimal radiologic service quality. Who would anticipate how many things can go wrong with a simple imaging requisition? Who would anticipate how these errors on imaging requisitions adversely affect high-quality patient care? At Riley Children’s Hospital, we have long felt that the quality of clinical information provided on our inpatient imaging requisitions is suboptimal. About 18 months ago, this prompted us to undertake an intensive quality assurance program, during which we analyzed the entire process by which the information is provided to radiologists on imaging requisitions. The study uncovered many unexpected problems and some unexpected obstacles to resolving common problems. Many articles have focused on the quality of imaging reports sent by radiologists to referring clinicians [2-4]. The ACR’s [5] Practice Guideline for Communication of Diagnostic Imaging addresses radiologists’ reports in great detail, while remaining completely silent regarding the information provided to radiologists on imaging requisitions. There is little published on the quality of imaging requisitions sent by clinicians to radiologists. Most of these reports focus only on improving the quality of clinical information on requisition [6-10]. There are other problems with requisitions. Khorasani [11] found that the ordering physician’s name was wrong up to 2% of the time. Cohen et al [12] studied requisitions from intensive care units. They found multiple errors in the written orders in patients’ charts and in the final orders printed out in the radiology systems from the hospital information systems. Radiology computer requisitions for 58 patients in intensive care units and the corresponding orders for the studies, written in the patients’ charts, were obtained. Each of the residents’ written chart orders was reviewed for completeness. The information entered 617
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into the radiology information systems by the ward secretaries (the radiology requisitions) was then directly compared with the actual orders written in the patients’ charts by the ward resident physicians. In 10% of the cases, no written orders were found in the patients’ medical records for the imaging studies. Clinical indications for the studies were provided by the residents in only 71% of cases. Residents’ names were missing in the charts in 14% of cases. In 84% of the cases, the residents failed to provide their pager numbers. In only 73% of the cases did the ward clerks exactly copy the clinical indication that was handwritten in the charts by the residents. In 21% of the cases, no residents’ names were provided as the ordering residents on the radiology requisitions. Other than complaining about the quality of clinical information provided to them on imaging requisitions, radiologists have done little to improve the accuracy of other important information provided on imaging requisitions. Poor communication between referring physicians and radiologists is frequently cited as a cause for diagnostic errors and poor quality [13]. I believe that there is a direct relationship between the quality of information provided by referring physicians to radiologists and the subsequent reports issued by the radiologists. The objectives of this article are to share with readers a comprehensive review of all of the problems that can occur with imaging requisitions and to suggest solutions to these problems. It is incumbent on radiologists to take ownership of these problems and to work with hospital administration and referring physicians to resolve them. PROBLEMS WITH IMAGING REQUISITIONS The lack of complete and accurate clinical information on imaging requisitions is a long-recognized problem [6,7,9,10]. Different institutions will have different problems with all of the information provided on their imaging requisitions. These problems extend beyond the quality of clinical information given to radiologists. Problems occur irrespective of whether an institution is operating with a completely paper environment, a completely electronic environment, or a mixture of both. No Requisition Available A patient may arrive at a radiology department for an imaging study and find that there is no imaging requisition in the department. There are many reasons for this problem. No requisition may have been completed at the time the study was ordered. The requisition may have been handwritten and not sent to the radiology department. The requisition may have been electronic and routed to the wrong printer. The absence of a requisition causes frustration to a patient, who has to wait while a requisition is obtained. Schedules are disrupted. The ab-
sence of a requisition wastes time for personnel, both in the radiology department and in the referring physician’s office. There may be a requisition in the referring physician’s office. Worse still, there may be no requisition at all. Long delays can occur as the referring physician’s staff members try to contact the physician to complete a requisition. Names of Attending and Ordering Physicians on Imaging Requisitions These may be the same or different names. At an academic institution, an order may be written by a resident or fellow. This name then appears as the ordering physician. The faculty attending physician’s name is then different. The name of the ordering physician, as it appears on an imaging requisition, may be either absent or incorrect. A radiologist may be unaware of the error. In a computer order entry system, the name will never be absent, because this is almost always a required entry field. However, it may be wrong. There are many reasons for an incorrect name. An order may have been handwritten, and the name may not be legible to the ward secretary transferring the information to a computer. The secretary then guesses the name. An order may not have been signed. Verbal orders may result in incorrect ordering physicians’ names being entered into the hospital information system. This may be because the secretary does not know the name of the ordering doctor and is too shy to ask. There may be a standing order; the physician who wrote the original order may not even be still looking after the patient. At Riley Children’s Hospital, we discovered that the name of the attending physician on an imaging order was very often wrong. Before our study, we were not aware of this problem. We learned that our hospital information system always populated the attending physician field with the name of the physician who had originally admitted the patient. This admitting physician’s name was displayed as the attending physician on every order throughout the patient’s hospital admission, even if the patient was transferred to another service. To overcome this problem, a method is needed by which the current attending physician is updated on a daily basis. This is very difficult to achieve. It requires either that the attending physician enter an order that a new attending physician is being assigned or that the information technology department can populate attending physician fields from work schedules. This problem is particularly bothersome in an academic environment. There are many adverse consequences of an order that contains an incorrect ordering or attending physician’s name. For significant problems, a radiologist may want to contact the physician directly. If the physician fields
Cohen/Imaging Requisition Accuracy 619
are incorrectly populated, the wrong physicians are phoned. This results in futile phone calls and a waste of time for both radiologists and clinical physicians. Another major problem is that the finalized radiology reports will be sent to the wrong physicians. This can result in errors in patient care. One unexpected, interesting problem we identified was a failure in the interface between our hospital information system and our radiology information system. When we crosschecked the name of the ordering physician as it appeared on a printed order from our radiology information system with the original handwritten order in the patient’s chart, we discovered discrepancies in about 20% of orders. Our initial inclination was to blame the ward secretaries; we believed that they were entering incorrect names from the written orders in the patients’ charts into the hospital information system. The ward secretaries were adamant that this was not the case. More detailed study of the problem identified a failure in communication between our hospital information and radiology information systems, such that the radiology information system was randomly changing the name of the ordering physician in about 20% of cases. Once discovered, this problem was easily corrected. This particular study reminded us of the importance of not arbitrarily and quickly assigning blame and to carefully, quantitatively document and analyze problems as we identified them. Phone and Pager Numbers of Ordering Physicians Imagine a radiologist sitting in a reading room. The radiologist needs to rapidly communicate with a referring physician to either obtain additional clinical information or convey important results. Ideally, the correct pager number of the referring physician is contained on the image requisition, and the radiologist rapidly makes contact with this individual. Unfortunately, this scenario frequently does not play out as desired. The provided data may be absent or incorrect. There may be a number of reasons for this. The ordering physician’s phone number or pager number may not have been provided. This may be because the numbers were not provided by the ordering physician or, in the case of a handwritten requisition, were not legible. In some scenarios, pager numbers and phone numbers may be automatically pulled from a database once the ordering physician’s name is entered into the hospital information system. This may fail if the database contains the wrong information or if the information is not available within the database. A final scenario that may play out is when an incorrect ordering physician’s name has been provided to a radiologist in an imaging order. In this situation, the radiologist’s time is wasted, and the physician contacted by the
radiologist has to answer an unnecessary page. This may cause the referring physician to waste time and, perhaps, feel anger and resentment toward the radiology department for this unwarranted call. This is particularly true if errors are repetitive. Problems with Standing Orders A radiologist is reading the morning intensive care unit chest radiographs. One imaging requisition provides a clinical history that reads “intubated check expansion of lungs.” The radiologist views the images and finds that the patient is not intubated. What has gone wrong? The most common cause for the scenario is the use of standing orders. Standing orders do have value and provide an easy mechanism for residents or attending physicians to obtain routine images of their patients. This may work well if standing orders are limited to 24 or 48 hours. Unfortunately, at some institutions, including Riley Children’s Hospital, there is no policy limiting the duration of standing orders, and the hospital and radiology information systems are not programmed to automatically terminate standing orders after a defined period of time, such as 48 hours. This has a very adverse outcome. First, patients may continue to receive repeated radiographs long beyond the time when they are truly clinically indicated. The above instance of daily radiographs continuing after extubation is an example of this situation. A second problem may occur if the patient has, for example, a 7:00 AM standing order for a chest x-ray and the ward attending physician has changed and, not being aware of the standing order, may order an additional radiograph within 1 or 2 hours of the standing order radiograph. Both of these scenarios provide unnecessary radiation to the patient and unnecessary charges being levied on the patient’s insurance provider. These are not the only adverse outcomes of the use of lengthy standing orders. Clinical care is affected because of the provision of bad or potentially incorrect clinical information. One problem with standing orders is that clinical information is entered at the time the standing orders are generated. If a standing order continues for days or weeks, the patient’s clinical situation may change dramatically from the time that the standing order was entered, and the unfortunate radiologist will be completely unaware of these changes in the patient’s clinical condition. It would seem appropriate to permit standing orders for a very limited time of 24 or 48 hours. This would include routine chest radiographs after surgery. It might also include routine radiographs every 6 to 8 hours for newborn infants on oscillator or jet ventilators. Standing orders should not, however, be permitted beyond 48 hours. Patients’ charts are routinely reviewed on a daily basis by ward residents and attending physicians. At these reviews, physicians routinely look at the patients’ vital
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signs, make changes to medications, and order fluids. At the same time that charts are being reviewed, decisions should be made regarding the requirement for radiographs within the next 24 hours and appropriate orders generated. There are many reasons why standing orders may not be stopped when the images are no longer needed. The simplest reason is that an ordering physician simply forgot to change or stop an order. In hospitals at which orders are still handwritten into charts, the appropriate pages may even have been removed from patients’ charts. With computer orders, the computer may not be programmed to alert ordering physicians that orders are still active, after a defined period of time. Worse still, the physicians generating standing orders may no longer be looking after the patients. Attending physicians and residents rotate on a regular basis. They change on a day-today basis, with different physicians in attendance during regular day hours and at nights and on weekends. Thus, the current attending physicians may not even be the individuals who generated the orders initially. In this situation, radiology reports would be sent to the incorrect physicians. This is poor-quality patient care. At Riley Children’s Hospital, although we would like to limit standing orders to 48 hours, we cannot do it. We cannot easily change our hospital information system. We are part of a large group of hospitals, and the hospital information system is such that a change can only be made on an enterprise-wide basis, not for an individual hospital. Radiologists may, surprisingly, not even be aware that standing orders are used at their hospitals. Radiologists must be aware of the extent of the use of standing orders and the problems this causes. They must act to limit or abolish their use. Use of Verbal Orders A very common reason for radiologists’ receiving poor or incorrect information on imaging requisitions is the use on the ward of verbal orders. Many radiologists are not even aware of the widespread use of verbal orders and why these are reasons for difficulties. It is reasonable for a radiologist to expect and trust that an order for an imaging study contains true and correct information regarding the patient. Why does the use of verbal orders adversely affect imaging requisitions? Most institutions have clear policies regarding the use of verbal orders. At most hospitals, they should be reserved for situations when physicians are not actually present on the wards. Verbal orders must be given to qualified health providers, usually nurses. Nurses are required to enter the orders in the patients’ charts or, if there is a computerized order entry system, directly into the system. If handwritten orders are used, the charts are
then given to ward secretaries, who enter the information into the hospital information system. The other situation in which verbal orders are permitted is in a genuine emergency situation in an intensive care unit. Unfortunately, it is common for these hospital policy regulations to be ignored. During ward rounds, verbal orders are frequently given by physicians to the nurses standing next to them. The orders may be entered into the hospital information system before they are entered into the patients’ records. In this situation, the provided clinical history may be changed or altered. It is also common for physicians to provide verbal orders to nurses without providing adequate clinical information. The nurses then generate what they believe to be the correct clinical indications. An even worse, but not uncommon, situation is when physicians communicate directly with ward secretaries, asking them to order imaging studies. In this situation, adequate clinical information is frequently not provided. The ward secretaries may then enter what they believe to be appropriately “acceptable” clinical histories. These histories include items such as “intubated,” “retape tube,” “respiratory distress,” and so on. Other problems may result from the use of verbal orders, in addition to poor or incorrect histories. These may include the ordering of incorrect studies. On some occasions, no final written order may be entered into patients’ charts, resulting in illegal patient billing. CONCLUSION In 2005, Leape and Berwick [14] reviewed the changes that had occurred in health care after the Institute of Medicine report, 5 years earlier, describing as many as 98,000 deaths each year in the United States due to medical errors. They concluded that progress was slow and that preventable injuries were still a problem. They believed that the most important stakeholders to advance the cause of patient safety are physicians and nurses. Radiologists are justified in believing that the information provided on imaging requisitions is timely, correct, and relevant. Unfortunately, this is frequently not true. Even worse is the fact that most radiologists may be completely unaware that the information on imaging requisitions is inaccurate. They may also be unaware of the scope of problems that may arise. These have been outlined in great detail above. Patient care suffers when the information provided on requisitions is inaccurate. Although there will always be human error, many of the problems outlined above are due to the existence of poor processes rather than being the result of bad people. New processes, such as direct physician order entry into hospital information systems, will help [11,15], but they will not solve all the problems.
Cohen/Imaging Requisition Accuracy 621
In the current era, the focus on quality is becoming more and more prevalent. This report draws attention to the potential problems that can occur with imaging requisitions. Only by being aware of the scope and nature of these problems can radiologists work together with hospital information technology staff members, administrators, ward secretaries, nursing staff members, and physicians to solve the problems. Radiologists must assume ownership of efforts to improve the communication provided from referring clinicians on radiology imaging requisitions. They must undertake studies to document the nature and extent of the problems at their institutions. Many hospitals have quality assurance personnel who can help perform these studies. Armed with the data from these studies, radiologists will get attention from physicians and hospital administrators. The next step is to establish committees to review and understand the processes involved and identify at exactly which step problems are occurring. Solutions will then vary depending on the actual problem. There may be simple computer problems that are easy to correct. Process problems will require a mix of altering the processes and education regarding the need for change and the adjustments that personnel are required to make. Success depends on ongoing reeducation. It also requires ongoing follow-up data collection to allow successes to be celebrated and failures to be followed by reevaluation and additional education. REFERENCES 1. Ruiz JA, Glazer GM. The state of radiology in 2006: very high spatial resolution but no visibility. Radiology 2006;241:11-6.
2. Langlotz CP. Automatic structuring of radiology reports: harbinger of a second information revolution in radiology. Radiology 2002;224:5-7. 3. Taira RK, Soderland SG, Jakobovits RM. Automatic structuring of radiology free-text reports. RadioGraphics 2001;21:237-45. 4. Lee R, Cohen MD, Jennings GS. A new method of evaluating the quality of radiology reports. Acad Radiol 2006;13:241-8. 5. American College of Radiology. ACR practice guideline for communication of diagnostic imaging findings. Reston, VA: American College of Radiology. 6. Gunderman RB, Phillips MD, Cohen MD. Improving clinical histories on radiology requisitions. Acad Radiol 2001;8:299-303. 7. Slovis TL, Frush D. Getting back to basics. Pediatr Radiol 2005;35: 839-40. 8. Cohen MD, Alam K. Radiology clinical synopsis: a simple solution for obtaining an adequate clinical history for the accurate reporting of imaging studies on patients in intensive care units. Pediatr Radiol 2005;35: 918-22. 9. Schuster DM, Gale ME. The malady of incomplete, inadequate, and inaccurate radiology requisition histories: a computerized treatment. AJR Am J Roentgenol 1996;167:855-9. 10. Gelford GJ. How to get clinical histories in a community general hospital without losing rapport with the medical staff. Radiology 1975;177: 487-8. 11. Khorasani R. Technology requirements for the optimal communication of critical test results. J Am Coll Radiol 2006;3:742-3. 12. Cohen MD, Curtin S, Lee R. Evaluation of the quality of radiology requisitions for intensive care unit patients. Acad Radiol 2006;13:236-40. 13. Gottlieb RH. Imaging for whom: patient or physician? AJR Am J Roentgenol 2005;185:1399-403. 14. Leape LL, Berwick DM. Five years after To err is human: what have we learned? JAMA 2005;293:2384-90. 15. Morin RL, Rosenthal DI, Stout MB. Radiology order entry: features and performance requirements. J Am Coll Radiol 2006;3:554-7.
Imaging requisitions are the major manner in which clinicians communicate to radiologists with regard to imaging studies they are requesting. Errors in the information provided on requisitions may have a deleterious effect on the quality of the imaging reports and services provided by radiologists. The author reviews all of the many problems and errors that can occur on imaging requisitions in addition to inadequate clinical histories. The author then discusses how to identify and resolve these errors. Key Words: Imaging requisition, communication, quality of radiology service J Am Coll Radiol 2007;4:617-621. Copyright © 2007 American College of Radiology
INTRODUCTION In an article published early in 2006, Ruiz and Glazer [1] reviewed in detail a New York Times article about a patient who had to wait several weeks to be informed that the results of a computed tomographic scan for suspected cancer were normal. The study had been interpreted by a radiologist about an hour after it was completed. The authors concluded that there is a need for direct communication between radiologists and patients. Their implication was that the report was sent to the internist, who failed to communicate the results to the patient for several weeks. They failed to consider other causes for the breakdown in communication. Could it have been due to an error on the imaging requisition? Could the wrong internist’s name have been provided and the report sent to the wrong internist? The need to provide high-quality care is intuitively obvious. The ability of current imaging technology to evaluate physiology, anatomy, and pathology is truly amazing. Superb computer technology allows the rapid transfer of images and information. To achieve highquality radiologic service, we cannot rely on our outstanding technology alone. Good bidirectional communication between radiologists and referring physicians remains an essential ingredient for the provision of highquality care. In the high-tech environment, a focus on the basic imaging requisition seems somewhat mundane and redundant. Many would say that the issue has been beaten to death. It does, however, remain an obstacle to Department of Radiology, Riley Children’s Hospital, Indiana University School of Medicine, Indianapolis, Indiana. Corresponding author and reprints: Mervyn D. Cohen, MB, ChB, MD, Riley Hospital for Children, Department of Radiology, 702 Barnhill Drive, Room 1053, Indianapolis, IN 46202; e-mail: [email protected]. © 2007 American College of Radiology 0091-2182/07/$32.00 ● DOI 10.1016/j.jacr.2007.02.003
optimal radiologic service quality. Who would anticipate how many things can go wrong with a simple imaging requisition? Who would anticipate how these errors on imaging requisitions adversely affect high-quality patient care? At Riley Children’s Hospital, we have long felt that the quality of clinical information provided on our inpatient imaging requisitions is suboptimal. About 18 months ago, this prompted us to undertake an intensive quality assurance program, during which we analyzed the entire process by which the information is provided to radiologists on imaging requisitions. The study uncovered many unexpected problems and some unexpected obstacles to resolving common problems. Many articles have focused on the quality of imaging reports sent by radiologists to referring clinicians [2-4]. The ACR’s [5] Practice Guideline for Communication of Diagnostic Imaging addresses radiologists’ reports in great detail, while remaining completely silent regarding the information provided to radiologists on imaging requisitions. There is little published on the quality of imaging requisitions sent by clinicians to radiologists. Most of these reports focus only on improving the quality of clinical information on requisition [6-10]. There are other problems with requisitions. Khorasani [11] found that the ordering physician’s name was wrong up to 2% of the time. Cohen et al [12] studied requisitions from intensive care units. They found multiple errors in the written orders in patients’ charts and in the final orders printed out in the radiology systems from the hospital information systems. Radiology computer requisitions for 58 patients in intensive care units and the corresponding orders for the studies, written in the patients’ charts, were obtained. Each of the residents’ written chart orders was reviewed for completeness. The information entered 617
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into the radiology information systems by the ward secretaries (the radiology requisitions) was then directly compared with the actual orders written in the patients’ charts by the ward resident physicians. In 10% of the cases, no written orders were found in the patients’ medical records for the imaging studies. Clinical indications for the studies were provided by the residents in only 71% of cases. Residents’ names were missing in the charts in 14% of cases. In 84% of the cases, the residents failed to provide their pager numbers. In only 73% of the cases did the ward clerks exactly copy the clinical indication that was handwritten in the charts by the residents. In 21% of the cases, no residents’ names were provided as the ordering residents on the radiology requisitions. Other than complaining about the quality of clinical information provided to them on imaging requisitions, radiologists have done little to improve the accuracy of other important information provided on imaging requisitions. Poor communication between referring physicians and radiologists is frequently cited as a cause for diagnostic errors and poor quality [13]. I believe that there is a direct relationship between the quality of information provided by referring physicians to radiologists and the subsequent reports issued by the radiologists. The objectives of this article are to share with readers a comprehensive review of all of the problems that can occur with imaging requisitions and to suggest solutions to these problems. It is incumbent on radiologists to take ownership of these problems and to work with hospital administration and referring physicians to resolve them. PROBLEMS WITH IMAGING REQUISITIONS The lack of complete and accurate clinical information on imaging requisitions is a long-recognized problem [6,7,9,10]. Different institutions will have different problems with all of the information provided on their imaging requisitions. These problems extend beyond the quality of clinical information given to radiologists. Problems occur irrespective of whether an institution is operating with a completely paper environment, a completely electronic environment, or a mixture of both. No Requisition Available A patient may arrive at a radiology department for an imaging study and find that there is no imaging requisition in the department. There are many reasons for this problem. No requisition may have been completed at the time the study was ordered. The requisition may have been handwritten and not sent to the radiology department. The requisition may have been electronic and routed to the wrong printer. The absence of a requisition causes frustration to a patient, who has to wait while a requisition is obtained. Schedules are disrupted. The ab-
sence of a requisition wastes time for personnel, both in the radiology department and in the referring physician’s office. There may be a requisition in the referring physician’s office. Worse still, there may be no requisition at all. Long delays can occur as the referring physician’s staff members try to contact the physician to complete a requisition. Names of Attending and Ordering Physicians on Imaging Requisitions These may be the same or different names. At an academic institution, an order may be written by a resident or fellow. This name then appears as the ordering physician. The faculty attending physician’s name is then different. The name of the ordering physician, as it appears on an imaging requisition, may be either absent or incorrect. A radiologist may be unaware of the error. In a computer order entry system, the name will never be absent, because this is almost always a required entry field. However, it may be wrong. There are many reasons for an incorrect name. An order may have been handwritten, and the name may not be legible to the ward secretary transferring the information to a computer. The secretary then guesses the name. An order may not have been signed. Verbal orders may result in incorrect ordering physicians’ names being entered into the hospital information system. This may be because the secretary does not know the name of the ordering doctor and is too shy to ask. There may be a standing order; the physician who wrote the original order may not even be still looking after the patient. At Riley Children’s Hospital, we discovered that the name of the attending physician on an imaging order was very often wrong. Before our study, we were not aware of this problem. We learned that our hospital information system always populated the attending physician field with the name of the physician who had originally admitted the patient. This admitting physician’s name was displayed as the attending physician on every order throughout the patient’s hospital admission, even if the patient was transferred to another service. To overcome this problem, a method is needed by which the current attending physician is updated on a daily basis. This is very difficult to achieve. It requires either that the attending physician enter an order that a new attending physician is being assigned or that the information technology department can populate attending physician fields from work schedules. This problem is particularly bothersome in an academic environment. There are many adverse consequences of an order that contains an incorrect ordering or attending physician’s name. For significant problems, a radiologist may want to contact the physician directly. If the physician fields
Cohen/Imaging Requisition Accuracy 619
are incorrectly populated, the wrong physicians are phoned. This results in futile phone calls and a waste of time for both radiologists and clinical physicians. Another major problem is that the finalized radiology reports will be sent to the wrong physicians. This can result in errors in patient care. One unexpected, interesting problem we identified was a failure in the interface between our hospital information system and our radiology information system. When we crosschecked the name of the ordering physician as it appeared on a printed order from our radiology information system with the original handwritten order in the patient’s chart, we discovered discrepancies in about 20% of orders. Our initial inclination was to blame the ward secretaries; we believed that they were entering incorrect names from the written orders in the patients’ charts into the hospital information system. The ward secretaries were adamant that this was not the case. More detailed study of the problem identified a failure in communication between our hospital information and radiology information systems, such that the radiology information system was randomly changing the name of the ordering physician in about 20% of cases. Once discovered, this problem was easily corrected. This particular study reminded us of the importance of not arbitrarily and quickly assigning blame and to carefully, quantitatively document and analyze problems as we identified them. Phone and Pager Numbers of Ordering Physicians Imagine a radiologist sitting in a reading room. The radiologist needs to rapidly communicate with a referring physician to either obtain additional clinical information or convey important results. Ideally, the correct pager number of the referring physician is contained on the image requisition, and the radiologist rapidly makes contact with this individual. Unfortunately, this scenario frequently does not play out as desired. The provided data may be absent or incorrect. There may be a number of reasons for this. The ordering physician’s phone number or pager number may not have been provided. This may be because the numbers were not provided by the ordering physician or, in the case of a handwritten requisition, were not legible. In some scenarios, pager numbers and phone numbers may be automatically pulled from a database once the ordering physician’s name is entered into the hospital information system. This may fail if the database contains the wrong information or if the information is not available within the database. A final scenario that may play out is when an incorrect ordering physician’s name has been provided to a radiologist in an imaging order. In this situation, the radiologist’s time is wasted, and the physician contacted by the
radiologist has to answer an unnecessary page. This may cause the referring physician to waste time and, perhaps, feel anger and resentment toward the radiology department for this unwarranted call. This is particularly true if errors are repetitive. Problems with Standing Orders A radiologist is reading the morning intensive care unit chest radiographs. One imaging requisition provides a clinical history that reads “intubated check expansion of lungs.” The radiologist views the images and finds that the patient is not intubated. What has gone wrong? The most common cause for the scenario is the use of standing orders. Standing orders do have value and provide an easy mechanism for residents or attending physicians to obtain routine images of their patients. This may work well if standing orders are limited to 24 or 48 hours. Unfortunately, at some institutions, including Riley Children’s Hospital, there is no policy limiting the duration of standing orders, and the hospital and radiology information systems are not programmed to automatically terminate standing orders after a defined period of time, such as 48 hours. This has a very adverse outcome. First, patients may continue to receive repeated radiographs long beyond the time when they are truly clinically indicated. The above instance of daily radiographs continuing after extubation is an example of this situation. A second problem may occur if the patient has, for example, a 7:00 AM standing order for a chest x-ray and the ward attending physician has changed and, not being aware of the standing order, may order an additional radiograph within 1 or 2 hours of the standing order radiograph. Both of these scenarios provide unnecessary radiation to the patient and unnecessary charges being levied on the patient’s insurance provider. These are not the only adverse outcomes of the use of lengthy standing orders. Clinical care is affected because of the provision of bad or potentially incorrect clinical information. One problem with standing orders is that clinical information is entered at the time the standing orders are generated. If a standing order continues for days or weeks, the patient’s clinical situation may change dramatically from the time that the standing order was entered, and the unfortunate radiologist will be completely unaware of these changes in the patient’s clinical condition. It would seem appropriate to permit standing orders for a very limited time of 24 or 48 hours. This would include routine chest radiographs after surgery. It might also include routine radiographs every 6 to 8 hours for newborn infants on oscillator or jet ventilators. Standing orders should not, however, be permitted beyond 48 hours. Patients’ charts are routinely reviewed on a daily basis by ward residents and attending physicians. At these reviews, physicians routinely look at the patients’ vital
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signs, make changes to medications, and order fluids. At the same time that charts are being reviewed, decisions should be made regarding the requirement for radiographs within the next 24 hours and appropriate orders generated. There are many reasons why standing orders may not be stopped when the images are no longer needed. The simplest reason is that an ordering physician simply forgot to change or stop an order. In hospitals at which orders are still handwritten into charts, the appropriate pages may even have been removed from patients’ charts. With computer orders, the computer may not be programmed to alert ordering physicians that orders are still active, after a defined period of time. Worse still, the physicians generating standing orders may no longer be looking after the patients. Attending physicians and residents rotate on a regular basis. They change on a day-today basis, with different physicians in attendance during regular day hours and at nights and on weekends. Thus, the current attending physicians may not even be the individuals who generated the orders initially. In this situation, radiology reports would be sent to the incorrect physicians. This is poor-quality patient care. At Riley Children’s Hospital, although we would like to limit standing orders to 48 hours, we cannot do it. We cannot easily change our hospital information system. We are part of a large group of hospitals, and the hospital information system is such that a change can only be made on an enterprise-wide basis, not for an individual hospital. Radiologists may, surprisingly, not even be aware that standing orders are used at their hospitals. Radiologists must be aware of the extent of the use of standing orders and the problems this causes. They must act to limit or abolish their use. Use of Verbal Orders A very common reason for radiologists’ receiving poor or incorrect information on imaging requisitions is the use on the ward of verbal orders. Many radiologists are not even aware of the widespread use of verbal orders and why these are reasons for difficulties. It is reasonable for a radiologist to expect and trust that an order for an imaging study contains true and correct information regarding the patient. Why does the use of verbal orders adversely affect imaging requisitions? Most institutions have clear policies regarding the use of verbal orders. At most hospitals, they should be reserved for situations when physicians are not actually present on the wards. Verbal orders must be given to qualified health providers, usually nurses. Nurses are required to enter the orders in the patients’ charts or, if there is a computerized order entry system, directly into the system. If handwritten orders are used, the charts are
then given to ward secretaries, who enter the information into the hospital information system. The other situation in which verbal orders are permitted is in a genuine emergency situation in an intensive care unit. Unfortunately, it is common for these hospital policy regulations to be ignored. During ward rounds, verbal orders are frequently given by physicians to the nurses standing next to them. The orders may be entered into the hospital information system before they are entered into the patients’ records. In this situation, the provided clinical history may be changed or altered. It is also common for physicians to provide verbal orders to nurses without providing adequate clinical information. The nurses then generate what they believe to be the correct clinical indications. An even worse, but not uncommon, situation is when physicians communicate directly with ward secretaries, asking them to order imaging studies. In this situation, adequate clinical information is frequently not provided. The ward secretaries may then enter what they believe to be appropriately “acceptable” clinical histories. These histories include items such as “intubated,” “retape tube,” “respiratory distress,” and so on. Other problems may result from the use of verbal orders, in addition to poor or incorrect histories. These may include the ordering of incorrect studies. On some occasions, no final written order may be entered into patients’ charts, resulting in illegal patient billing. CONCLUSION In 2005, Leape and Berwick [14] reviewed the changes that had occurred in health care after the Institute of Medicine report, 5 years earlier, describing as many as 98,000 deaths each year in the United States due to medical errors. They concluded that progress was slow and that preventable injuries were still a problem. They believed that the most important stakeholders to advance the cause of patient safety are physicians and nurses. Radiologists are justified in believing that the information provided on imaging requisitions is timely, correct, and relevant. Unfortunately, this is frequently not true. Even worse is the fact that most radiologists may be completely unaware that the information on imaging requisitions is inaccurate. They may also be unaware of the scope of problems that may arise. These have been outlined in great detail above. Patient care suffers when the information provided on requisitions is inaccurate. Although there will always be human error, many of the problems outlined above are due to the existence of poor processes rather than being the result of bad people. New processes, such as direct physician order entry into hospital information systems, will help [11,15], but they will not solve all the problems.
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In the current era, the focus on quality is becoming more and more prevalent. This report draws attention to the potential problems that can occur with imaging requisitions. Only by being aware of the scope and nature of these problems can radiologists work together with hospital information technology staff members, administrators, ward secretaries, nursing staff members, and physicians to solve the problems. Radiologists must assume ownership of efforts to improve the communication provided from referring clinicians on radiology imaging requisitions. They must undertake studies to document the nature and extent of the problems at their institutions. Many hospitals have quality assurance personnel who can help perform these studies. Armed with the data from these studies, radiologists will get attention from physicians and hospital administrators. The next step is to establish committees to review and understand the processes involved and identify at exactly which step problems are occurring. Solutions will then vary depending on the actual problem. There may be simple computer problems that are easy to correct. Process problems will require a mix of altering the processes and education regarding the need for change and the adjustments that personnel are required to make. Success depends on ongoing reeducation. It also requires ongoing follow-up data collection to allow successes to be celebrated and failures to be followed by reevaluation and additional education. REFERENCES 1. Ruiz JA, Glazer GM. The state of radiology in 2006: very high spatial resolution but no visibility. Radiology 2006;241:11-6.
2. Langlotz CP. Automatic structuring of radiology reports: harbinger of a second information revolution in radiology. Radiology 2002;224:5-7. 3. Taira RK, Soderland SG, Jakobovits RM. Automatic structuring of radiology free-text reports. RadioGraphics 2001;21:237-45. 4. Lee R, Cohen MD, Jennings GS. A new method of evaluating the quality of radiology reports. Acad Radiol 2006;13:241-8. 5. American College of Radiology. ACR practice guideline for communication of diagnostic imaging findings. Reston, VA: American College of Radiology. 6. Gunderman RB, Phillips MD, Cohen MD. Improving clinical histories on radiology requisitions. Acad Radiol 2001;8:299-303. 7. Slovis TL, Frush D. Getting back to basics. Pediatr Radiol 2005;35: 839-40. 8. Cohen MD, Alam K. Radiology clinical synopsis: a simple solution for obtaining an adequate clinical history for the accurate reporting of imaging studies on patients in intensive care units. Pediatr Radiol 2005;35: 918-22. 9. Schuster DM, Gale ME. The malady of incomplete, inadequate, and inaccurate radiology requisition histories: a computerized treatment. AJR Am J Roentgenol 1996;167:855-9. 10. Gelford GJ. How to get clinical histories in a community general hospital without losing rapport with the medical staff. Radiology 1975;177: 487-8. 11. Khorasani R. Technology requirements for the optimal communication of critical test results. J Am Coll Radiol 2006;3:742-3. 12. Cohen MD, Curtin S, Lee R. Evaluation of the quality of radiology requisitions for intensive care unit patients. Acad Radiol 2006;13:236-40. 13. Gottlieb RH. Imaging for whom: patient or physician? AJR Am J Roentgenol 2005;185:1399-403. 14. Leape LL, Berwick DM. Five years after To err is human: what have we learned? JAMA 2005;293:2384-90. 15. Morin RL, Rosenthal DI, Stout MB. Radiology order entry: features and performance requirements. J Am Coll Radiol 2006;3:554-7.