- Email: [email protected]
Communicating Radiology Test Results
ARTICLE IN PRESS
Original Investigation
Communicating Radiology Test Results: Are Our Phone Calls Excessive, Just Right, or Not Enough? Zeeshaan S. Bhatti, MD, Richard K. J. Brown, MD, Ella A. Kazerooni, MD, MS, Matthew S. Davenport, MD Rationale and Objectives: This study aimed to determine the preferences of radiology and referring provider residents regarding direct communication of radiology test results. Methods: This Health Insurance Portability and Accountability Act-compliant quality improvement effort was exempt from institutional review board oversight. An anonymous survey was emailed to 44 radiology residents and 364 referring resident providers who routinely provide or receive direct communication of test results at our quaternary care medical center. The survey focused on the frequency, indication, clinical utility, and methods of direct communication of radiology results. Proportions were compared to chi-square or Fisher exact test. Results: The response rates were 86% (37 of 43) (radiology) and 41% (151 of 364) (referring providers). Approximately half of radiology residents (49% [18 of 37]) thought the frequency of direct verbal communication was excessive, and none (0 of 37) thought more communication was needed. In contrast, only 1.3% (2 of 151; P < .001) of referring providers felt the frequency was excessive, and 24% (36 of 151; P < .001) desired more. The majority (66% [100 of 151]) of referring providers felt phone calls from radiologists often or always added value beyond a timely radiology report, and 59% (44 of 74) felt it is the radiologist’s responsibility to call about abnormal findings. Furthermore, 83% (125 of 151) of referring providers preferred to receive a phone call about non-emergent unexpected findings, although preferences varied for various example abnormalities. For outpatients with non-emergent unexpected findings, most providers (90% [64 of 71]) prefer written communication rather than a phone call. Conclusions: Referring providers prefer direct communication of radiology results, even for non-urgent unexpected findings, whereas radiology residents prefer less direct communication and are more likely to consider radiologist-to-provider communication superfluous. Key Words: Communication; quality; multidisciplinary; collaboration; value; results; closed-loop. © 2017 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.
INTRODUCTION
T
he American College of Radiology Practice Parameter for the Communication of Diagnostic Imaging Findings (1) states that “quality patient care can only be achieved when study results are conveyed in a timely fashion to those responsible for treatment decisions,” and advises that the interpreting physician should expedite communication of emergent or non-routine results in a way that ensures they will be received in a timely fashion “to provide the most benefit Acad Radiol 2017; ■:■■–■■ From the Department of Radiology, University of Michigan Health System, 1500 E. Medical Center Dr. B2-A209P, Ann Arbor, Michigan, 48108 (Z.S.B., R.KJ.B., E.A.K., M.S.D.); Michigan Radiology Quality Collaborative, 1500 E. Medical Center Dr. B2-A209P, Ann Arbor, Michigan, 48108 (R.KJ.B., E.A.K., M.S.D.). Received July 18, 2017; revised September 20, 2017; accepted September 21, 2017. Funding: No extramural funding solicited or used for this work. Address correspondence to: M.S.D. e-mail: [email protected] © 2017 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.acra.2017.09.015
to the patient” (1). Similarly, The Joint Commission has prioritized effective communication as a national Patient Safety Goal (2), and requires that critical, urgent, and unexpected findings be communicated directly to the referring provider in a closed-loop fashion. Together, these establish a clear practice standard that requires certain non-routine test results be communicated directly. However, there is a “gray area” in which a radiology test result could arguably be delivered electronically rather than by phone, or by open- rather than closed-loop communication. With the ever-rising volume of radiologic testing, this equipoise occurs on a daily basis, and is a source of anxiety and frustration for radiologists. When confronted with this situation, radiologists are often torn between a medico-legal pressure to communicate, an uncertainty about the relevance of the finding in question, competing pressures that demand they continue their other work, and a feeling that the recipient of their message may be irritated at the interruption—particularly if asked to call the radiologist back. 1
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This is especially true overnight, when on-call radiologists and their referring providers are doing work at an accelerated pace in a higher acuity environment, and referring providers may be less available to receive direct communication. Given these competing priorities, we wanted to explore the sentiments of both radiology and referring provider residents with respect to the delivery and receipt of directly communicated radiology test results. It was our hope this would better inform the decision-making process of radiologists caught in the balancing act of whether and how to communicate radiology findings. Resident providers were targeted because they were perceived to be most familiar with the pressures of on-call work, and are poised to become the next generation of attending physicians. Our purpose was to determine the preferences of radiology and referring provider residents regarding direct communication of radiology test results.
METHODS This Health Insurance Portability and Accountability Actcompliant prospective quality improvement effort was “not regulated” by the host institutional review board (ie, exempt from institutional review board oversight). No protected health information was collected or analyzed. No extramural funding was used.
Subjects
Anonymous surveys were delivered electronically through a Health Insurance Portability and Accountability Act-compliant anonymous online platform (Qualtrics.com) to 43 diagnostic radiology residents and 364 residents from the emergency medicine, surgery, and internal medicine residencies at our quaternary care institution. Surgical residents were from the following residency programs: general surgery, vascular surgery, plastic surgery, cardiothoracic surgery, oral and maxillofacial surgery, otolaryngology, and urology. Surveys were sent over a 3-day period in December 2016. Respondents were encouraged to respond by being informed that the results may be used to influence local radiologist practice patterns. There were two similarly themed surveys— one for the radiology residents and one for the referring providers—reflecting their different roles in the delivery and receipt of radiology test results. Surveys focused on the frequency, indication, clinical utility, and methods of direct communication of radiology test results. Internal medicine residents were asked two additional questions regarding receipt of non-emergent radiology results for examinations performed on outpatients. In addition to their current opinions, radiology residents also were asked specifically about their experience serving as referring providers during their intern year. Free-text commentary was solicited from referring providers about the effect of direct communication on daily work. The surveys are provided in Appendix A, and the free-text responses are provided in Appendix B. 2
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Local Communications Policy
It is the local policy at our institution for radiologists to directly communicate to a member of the treatment team in a closed-loop fashion any of the following types of radiologic findings: critical, urgent, unexpected, medically significant change from a resident preliminary report. This most commonly involves a page with a note to call the radiologist back at a specified phone number. For inpatients, a “first contact” for the care team is listed in our electronic medical record system (Epic, Verona, WI). For emergency department patients, the ordering provider includes in the radiology order a call-back number of a portable phone they carry during their shift for radiologists to call directly. On call, radiology residents dictate and sign preliminary results using electronic dictation software (Powerscribe 360, Nuance Communications, Burlington, MA). The preliminary result is sent to the radiology chart review section of the electronic medical record system and is immediately visible to the treatment teams. For time-sensitive findings that are anticipated to have an immediate effect on patient care, it is policy to discuss the results verbally, which is usually by phone and may be in person. For other findings that need non-emergent communication, residents are encouraged to use the internal messaging system integrated into the electronic medical record system. For context, out of 555,805 finalized radiology reports generated at our institution over the 1-year period from October 2015 to September 2016, the proportion of reports with documented communication using our standardized internal templates was 15.9% (88,295 of 555,805). This included 12.4% (69,186 of 555,805) flagged “routine,” 2.2% (12,203 of 555,805) flagged “unexpected,” 0.7% (3987 of 555,805) flagged “urgent,” and 0.5% (2919 of 555,805) flagged “critical.” This is an underestimation of the total number of communications because it reflects only those that used the standardized templates.
Data Analysis
The type of practice at which each of the radiology residents did their preliminary or transitional year before entering radiology residency was recorded. Descriptive statistics (proportions) were calculated. Proportions were compared between specialties to chi-square or Fisher exact test. P < .05 was considered significant for hypothesis testing.
RESULTS The response rates were 86% (37 of 43) for radiology residents and 41% (151 of 364) for referring resident providers (emergency medicine: 48% [32 of 67]; surgery: 34% [45 of 134]; internal medicine: 45% [74 of 163]), with representation from all post-graduate year levels for all specialties (Table 1). Most (79%) radiology residents had done their preliminary or transitional year training at a community hospital (n = 31)
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COMMUNICATING RADIOLOGY TEST RESULTS
TABLE 1. Respondent Training Program and Post-Graduate Year (pgy) Level Residency and Training Level Diagnostic Radiology Invited Participated Post-graduate year 2 Post-graduate year 3 Post-graduate year 4 Post-graduate year 5 Emergency Medicine Invited Participated Post-graduate year 1 Post-graduate year 2 Post-graduate year 3 Post-graduate year 4+ Surgery Invited Participated Post-graduate year 1 Post-graduate year 2 Post-graduate year 3 Post-graduate year 4+ Internal Medicine Invited Participated Post-graduate year 1 Post-graduate year 2 Post-graduate year 3 Post-graduate year 4+
Data 43 37 24% (9/37) 24% (9/37) 27% (10/37) 24% (9/37) 67 32 25% (8/32) 28% (9/32) 25% (8/32) 22% (7/32) 134 45 24% (11/45) 18% (8/45) 11% (5/45) 47% (21/45) 163 74 38% (28/74) 30% (22/74) 26% (19/74) 7% (5/74)
or hybrid academic practice (n = 3). None did so at the study institution. There were differences in perception between radiology residents and referring resident providers regarding the need, frequency, and value of direct radiologist communication (Tables 2–3). In general, radiology residents were more likely to consider their communications to be excessive or of minimal value compared to the referring resident providers who received them (Tables 2–3). Approximately half of radiology residents (49% [18 of 37]) thought the frequency of direct verbal communication was excessive, and none (0 of 37) thought more communication was needed (Table 2). In contrast, only 1.3% (2 of 151; P < .001) of referring providers felt the frequency was excessive, and 24% (36 of 151; P < .001) desired more (Table 3). The majority (66% [100 of 151]) of referring providers felt phone calls from radiologists often or always added value beyond a timely radiology report compared to only 41% (15 of 37) of radiology residents (P = .005). Interestingly, radiology residents were likely to remember not being phoned by radiologists during their intern year when they were functioning as referring providers (Table 2) (ie, a time in which they were not functioning as practicing radiologists), which was in contrast to the high frequency reported by referring resident providers (Table 3). More than half (54% [20 of 37])
of radiology residents stated that they anticipated communicating less often when they become attending practitioners. The majority of referring providers (83% [125 of 151]) preferred to receive a phone call about both emergent and nonemergent unexpected findings (Tables 3–4), with a minority stating they wished to be phoned only if the finding was emergent (Table 3). Of the 11 specific diagnoses we interrogated (Table 4), those that referring providers most strongly wished to be phoned directly about were acute stroke (91%–94%) and aortic rupture (89%–100%) (Table 1); interestingly, a small minority of referring providers wished not to be contacted by phone about anything, even an aortic rupture (Table 4). The diagnoses with the least preference for direct phone communication were pneumonia (19%–28%), acute fracture (27%– 49%), and obstructing urinary calculus (31%–46%) (Table 4). Most internal medicine providers (59% [44 of 74]) felt it is in part the radiologist’s responsibility to call the referring provider regarding non-emergent abnormal findings in outpatients (Table 3), although a large minority (41% [30 of 74]) stated they assumed full responsibility for looking up the results of the outpatient tests they ordered and did not expect the radiologist to notify them (Table 3). For outpatients with nonemergent unexpected findings, most providers (90% [64 of 71]) prefer written communication (ie, either in the radiology report or by electronic messaging) rather than a phone call (Table 3). DISCUSSION The importance of effective and appropriate radiologist-toprovider communication is multifold. Misdiagnosis and delayed diagnosis are common major causes of health care-associated morbidity and mortality (3–6), and are exacerbated by a failure to communicate (6). Delays in communication contribute to delayed diagnosis (6), which in turn delays effective and appropriate treatment (6). In addition, failure to communicate is a common source of liability for practicing radiologists (7,8). Although radiologists may feel internal and external pressure to avoid direct communication, and a tendency to minimize the importance of the communication they provide, our results demonstrate that referring providers in general find radiologist input to be valuable and worthwhile, and are much more likely than radiologists to feel that direct verbal communication is important, even for non-emergent unexpected results. Although we did not study the reasons behind why radiology residents prefer to avoid communication, we offer some speculative explanations. Radiologists may be more likely anti-social, afraid of confrontation, too busy, or reluctant to expose themselves to criticism. If the literature supporting clear lines of direct communication is not compelling (3–8), our data should reassure radiologists that the recipients of their communications in general welcome them and do not consider them a nuisance. Other studies have analyzed the usefulness of radiologist communication. Siewert et al. (9) performed a 10-year retrospective review of 380 communication errors and found 3
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TABLE 2. Radiology Resident Responses (n = 37 Respondents) Question
Diagnostic Radiology
During your intern year, how often did you get a phone call from a radiologist regarding abnormal radiology test results? Never Rarely (ie, only a couple times during the year) On occasion (ie, a couple times a month) Frequently (ie, a couple times a week) Very frequently (ie, daily) During your intern year, how often did you get a phone call from a radiologist regarding a study protocol? Never Rarely (ie, only a couple times during the year) On occasion (ie, a couple times a month) Frequently (ie, a couple times a week) Very frequently (ie, daily) As a department, what do you think about the frequency of our communication of test results directly to clinicians? Too much Appropriate Too infrequent Do you sometimes contact clinicians with radiology results despite knowing they are aware of the findings? Yes, often Yes, infrequently No Don't know, I never check the patient's chart to see if they're aware In your future practice (ie, as an attending), how frequently do you anticipate directly communicating findings compared to now? Less likely About the same More likely How often do you think communicating abnormal test results directly to clinicians adds anything valuable beyond a timely radiology report? Never Rarely On occasion Often Always
that errors in results communication were the most common cause of radiology communication errors (48%), with 25% of these having a major impact on patient care. Dickerson et al. (10) prospectively studied the impact of in-person communication between radiologists and acute care surgeons, and measured whether that interaction affected patient care beyond the printed final radiology report. Out of 100 subjects, they found that direct communication changed attending surgeon impression in 43% and changed medical or surgical planning in 43%; interestingly, these 43% were not entirely overlapping. The authors concluded that in-person collaboration affected care by promoting “a shared mental model that facilitates the exchange of complex information” (10). Given that the work of a diagnostic radiologist is fundamentally the translation of imaging data into actionable information (11,12), the value of a radiologist is inextricable from their ability to effectively communicate. An expert radiologist who cannot or does not communicate is an ineffective radiologist. 4
43% (16/37) 35% (13/37) 16% (6/37) 3% (1/37) 3% (1/37) 73% (27/37) 14% (5/37) 3% (1/37) 11% (4/37) 0% (0/37)
49% (18/37) 51% (19/37) 0% (0/37) 60% (22/37) 24% (9/37) 8% (3/37) 8% (3/37)
54% (20/37) 43% (16/37) 3% (1/37)
0% (0/37) 5% (2/37) 54% (20/37) 38% (14/37) 3% (1/37)
One of the paradoxical findings from our data was that radiology residents were very likely to remember not being contacted by radiologists during their intern year, which stood in contrast to the frequency of radiologist communication reported by our referring resident providers. This may be because the intern training of most of the radiology residents was often at a community hospital staffed by private practice radiologists, who may have had a different practice paradigm than the academic setting that was the focus of this investigation. Given that approximately 70% of our radiology residents end up in private practice after residency, this may in part account for the perception among more than half (54% [20 of 37]) that they would communicate less with referring providers after they graduated. We would like to reinforce that they should continue to communicate in practice! Our results have limitations. The survey was administered to resident radiologists and referring providers at a single academic institution. Communication is prioritized in our
Question
Emergency Medicine
Surgery
* Only asked of internal medicine residents. Not all respondents answered every question.
Combined
1% (1/74) 4% (3/74) 45% (33/74) 47% (35/74) 3% (2/74)
1% (2/151) 9% (13/151) 36% (54/151) 39% (59/151) 15% (23/151)
1% (1/74) 28% (21/74) 59% (44/74) 9% (7/74) 1% (1/74)
1% (2/151) 27% (41/151) 52% (78/151) 16% (24/151) 4% (6/151)
1% (1/74) 74% (55/74) 24% (18/74)
1% (2/151) 75% (113/151) 24% (36/151)
1% (1/74) 7% (5/74) 22% (16/74) 55% (41/74) 15% (11/74)
1% (1/151) 7% (10/151) 26% (40/151) 54% (82/151) 12% (18/151)
14% (10/74) 84% (62/74) 3% (2/74) 0% (0/74)
11% (16/151) 83% (125/151) 5% (7/151) 0% (0/151)
27% (19/71) 63% (45/71) 10% (7/71)
— — —
41% (30/74) 59% (44/74
— —
0% (0/74)
—
5
COMMUNICATING RADIOLOGY TEST RESULTS
How often do you get a phone call from a radiologist regarding abnormal test results? Never 0% (0/32) 2% (1/45) Rarely (ie, only a couple times during the year) 0% (0/32) 22% (10/45) On occasion (ie, a couple times a month) 3% (1/32) 44% (20/45) Frequently (ie, a couple times a week) 34% (11/32) 29% (13/45) Very frequently (ie, daily) 63% (20/32) 2% (1/45) How often do you get a phone call from a radiologist regarding a study protocol (ie, type of study, contrast issues)? Never 0% (0/32) 2% (1/45) Rarely (ie, only a couple times during the year) 6% (2/32) 40% (18/45) On occasion (ie, a couple times a month) 38% (12/32) 49% (22/45) Frequently (ie, a couple times a week) 44% (14/32) 7% (3/45) Very frequently (ie, daily) 13% (4/32) 2% (1/45) What do you think about the frequency of phone calls regarding test results from radiologists? Too frequent, they need to cut back 3% (1/32) 0% (0/45) Appropriate 75% (24/32) 76% (34/45) Not enough, they're helpful and I would prefer more phone calls 22% (7/32) 24% (11/45) How often does a phone call from a radiologist add anything valuable beyond the radiology report? Never 0% (0/32) 0% (0/45) Rarely 1% (1/32) 9% (4/45) On occasion 31% (10/32) 31% (14/45) Often 63% (20/32) 47% (21/45) Always 3% (1/32) 13% (6/45) If radiology reports are available in a timely manner, what would be your preference? Receive a phone call only about emergent findings 16% (5/32) 9% (4/45) Receive a phone call about emergent and also non-emergent abnormal or unexpected findings 81% (26/32) 82% (37/45) Receive a page when the report is available 3% (1/32) 9% (4/45) Not receive a phone call or a page about any findings, I would prefer to check the report myself according to my 0% (0/32) 0% (0/45) own workflow *What is your preference for communication of non-emergent abnormal radiology results specifically for outpatients? I don't want to be interrupted about it, I would prefer to review the results myself I prefer a message via the internal electronic medical record messaging system or via my pager I prefer a phone call *Regarding non-emergent radiology results, which of the following do you most agree with? It is my responsibility to follow-up on results for a study I ordered, not the radiologists' responsibility to call about abnormal results. It is primarily my responsibility to follow-up on results for a study I ordered, but it is also the radiologist's responsibility to call about abnormal results. It is not primarily my responsibility to follow-up on results for a study I ordered; it is primarily the radiologist's responsibility to call about abnormal results.
Internal Medicine
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TABLE 3. Referring Resident Provider Responses (n = 32 Emergency Medicine, n = 45 Surgery, n = 74 Internal Medicine).
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TABLE 4. Diagnosis-specific Preferences for Method of Notification by Referring Provider Respondents (n = 32 Emergency Medicine [EM], n = 45 Surgery [S], n = 74 Internal Medicine [IM]) Discussion by Phone (Closed-loop Communication) Radiology Diagnosis Acute fracture Acute appendicitis Pneumonia Malpositioned tube or catheter Acute stroke New mass or suspected cancer Pulmonary embolism Aortic rupture Retroperitoneal hemorrhage without active bleeding Small bowel obstruction Obstructing urinary calculus
Pager Notification (Call Back Not Required)
Do Not Contact
EM
S
IM
EM
S
IM
EM
S
IM
47% (15) 72% (23) 28% (9) 72% (23) 94% (30) 54% (17) 78% (25) 100% (32) 69% (22)
27% (12) 44% (20) 19% (8) 52% (23) 91% (40) 42% (19) 82% (37) 91% (41) 47% (21)
49% (36) 76% (56) 18% (13) 57% (42) 92% (68) 64% (47) 80% (59) 89% (66) 64% (47)
38% (12) 25% (8) 56% (18) 22% (7) 6% (2) 41% (13) 16% (5) 0% (0) 25% (8)
61% (27) 51% (23) 65% (28) 48% (21) 9% (4) 51% (23) 18% (8) 9% (4) 49% (22)
44% (32) 20% (15) 49% (36) 38% (28) 8% (6) 34% (25) 18% (13) 9% (7) 32% (24)
16% (5) 3% (1) 16% (5) 6% (2) 0% (0) 6% (2) 6% (2) 0% (0) 6% (2)
11% (5) 4% (2) 16% (7) 0% (0) 0% (0) 7% (3) 0% (0) 0% (0) 4% (2)
7% (5) 4% (3) 34% (25) 5% (4) 0% (0) 3% (2) 3% (2) 1% (1) 4% (3)
59% (19) 44% (14)
32% (14) 31% (13)
54% (40) 46% (34)
34% (11) 50% (16)
48% (21) 52% (22)
39% (29) 45% (33)
6% (2) 6% (2)
20% (9) 17% (7)
7% (5) 9% (7)
Numbers in parentheses are N. Not all respondents answered every question. Denominators are the number of respondents within each specialty that responded to each diagnosis.
radiology department—15.9% of finalized radiology reports contain structured text indicating that some form of radiologistto-provider communication took place. Therefore, our results may not apply to community hospitals, academic hospitals with less aggressive communications policies, or attending practitioners with different knowledge or priorities. However, the methods of communication and practice patterns learned by residents form the basis for future practice, and it is plausible that our results might be similar at other sites. Although our response rate was adequate (13), it is possible that nonrespondents had different points of view that could have altered our conclusions had they participated. Finally, subtle differences in wording of the questions in our survey may have affected the responses we received. Therefore, validation of our results in separate practice settings using questions that probe similar content would be important to assure the generalizability of our findings. In conclusion, referring resident providers prefer direct communication of radiology results, even for non-urgent unexpected findings, whereas radiology residents prefer less direct communication and are more likely to consider radiologist-toprovider communication superfluous. Our results provide additional support for the notion that direct radiologist-toprovider communication is important, desired, and valuable for patient care, and highlights an opportunity for education of radiologist trainees about the value of this activity. Investigating ways to streamline communication—such as by leveraging information technology solutions (14)—is likely to be worthwhile, thought it will be important to compare the clinical and inter-personal outcomes achieved by such solutions (ie, beyond simple transactional receipt of a report) against the ideals of in-person and direct vocal communication (10) by radiologists acting as both information broker and consultant physician (15). At a time when radiologists are often 6
disconnected physically from referring providers, efforts to maximize effective and timely communication are essential elements of the value radiology brings to patient care. REFERENCES 1. ACR. Practice Parameter for Communication of Diagnostic Imaging Findings. Revised 2014. Available at: https://www.acr.org/~/media/ C5D1443C9EA4424AA12477D1AD1D927D.pdf. Accessed 5/18/2017. 2. The Joint Commission. National Patient Safety Goals. Effective: 1/1/2015. Critical Access Hospital Accreditation Program. Available at: http://www.jointcommission.org/assets/1/6/2015_NPSG_CAH.pdf. Accessed 5/18/2017. 3. Graber ML. The incidence of diagnosis error in medicine. BMJ Qual Saf 2013; 22(suppl 2):ii21–ii27. 4. Singh H, Meyer AN, Thomas EJ. The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations. BMJ Qual Saf 2014; 23:727–731. 5. Murphy DR, Singh H, Berlin L. Communication breakdown and diagnostic errors: a radiology perspective. Diagnosis 2014; 1:253–261. 6. Institute of Medicine. Improving diagnosis in health care. Washington, DC: National Academies of Sciences, Engineering, and Medicine, 2015. Available at: http://www.nationalacademies.org/hmd/Reports/2015/ Improving-Diagnosis-in-Healthcare.aspx. 7. Schwinger HN. Liability problems in radiology communications exist. ACR Bulletin 46:33. 1990 8. Berlin L. Communicating nonroutine radiologic findings to the ordering physician: will (should) information technology-assisted communication replace direct voice contact? Radiology 2015; 277:332–336. 9. Siewert B, Brook OR, Hochman M, et al. Impact of communication errors in radiology on patient care, customer satisfaction, and work-flow efficiency. AJR Am J Roentgenol 2016; 206:573–579. 10. Dickerson EC, Alam HB, Brown RK, et al. In-person communication between radiologists and acute care surgeons leads to significant alterations in surgical decision making. J Am Coll Radiol 2016; 13:943– 949. 11. Baron RL. The radiologist as interpreter and translator. Radiology 2014; 272:4–8. 12. Boland GW, Duszak R, Jr, Larson PA. Communication of actionable information. J Am Coll Radiol 2014; 11:1019–1021. 13. Nulty DD. The adequacy of response rates to online and paper surveys: what can be done? Assessment and Evaluation in Higher Education 2008; 33:301–314.
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14. Eisenberg RL, Yamada K, Yam CS, et al. Electronic messaging system for communicating important, but nonemergent, abnormal imaging results. Radiology 2010; 257:724–731. 15. Baker SR. Transmission of nonemergent critical findings: communication versus consultation. Radiology 2010; 257:609–611.
COMMUNICATING RADIOLOGY TEST RESULTS
SUPPLEMENTARY DATA Supplementary data related to this article can be found at https://doi.org/10.1016/j.acra.2017.09.015.
7
Original Investigation
Communicating Radiology Test Results: Are Our Phone Calls Excessive, Just Right, or Not Enough? Zeeshaan S. Bhatti, MD, Richard K. J. Brown, MD, Ella A. Kazerooni, MD, MS, Matthew S. Davenport, MD Rationale and Objectives: This study aimed to determine the preferences of radiology and referring provider residents regarding direct communication of radiology test results. Methods: This Health Insurance Portability and Accountability Act-compliant quality improvement effort was exempt from institutional review board oversight. An anonymous survey was emailed to 44 radiology residents and 364 referring resident providers who routinely provide or receive direct communication of test results at our quaternary care medical center. The survey focused on the frequency, indication, clinical utility, and methods of direct communication of radiology results. Proportions were compared to chi-square or Fisher exact test. Results: The response rates were 86% (37 of 43) (radiology) and 41% (151 of 364) (referring providers). Approximately half of radiology residents (49% [18 of 37]) thought the frequency of direct verbal communication was excessive, and none (0 of 37) thought more communication was needed. In contrast, only 1.3% (2 of 151; P < .001) of referring providers felt the frequency was excessive, and 24% (36 of 151; P < .001) desired more. The majority (66% [100 of 151]) of referring providers felt phone calls from radiologists often or always added value beyond a timely radiology report, and 59% (44 of 74) felt it is the radiologist’s responsibility to call about abnormal findings. Furthermore, 83% (125 of 151) of referring providers preferred to receive a phone call about non-emergent unexpected findings, although preferences varied for various example abnormalities. For outpatients with non-emergent unexpected findings, most providers (90% [64 of 71]) prefer written communication rather than a phone call. Conclusions: Referring providers prefer direct communication of radiology results, even for non-urgent unexpected findings, whereas radiology residents prefer less direct communication and are more likely to consider radiologist-to-provider communication superfluous. Key Words: Communication; quality; multidisciplinary; collaboration; value; results; closed-loop. © 2017 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.
INTRODUCTION
T
he American College of Radiology Practice Parameter for the Communication of Diagnostic Imaging Findings (1) states that “quality patient care can only be achieved when study results are conveyed in a timely fashion to those responsible for treatment decisions,” and advises that the interpreting physician should expedite communication of emergent or non-routine results in a way that ensures they will be received in a timely fashion “to provide the most benefit Acad Radiol 2017; ■:■■–■■ From the Department of Radiology, University of Michigan Health System, 1500 E. Medical Center Dr. B2-A209P, Ann Arbor, Michigan, 48108 (Z.S.B., R.KJ.B., E.A.K., M.S.D.); Michigan Radiology Quality Collaborative, 1500 E. Medical Center Dr. B2-A209P, Ann Arbor, Michigan, 48108 (R.KJ.B., E.A.K., M.S.D.). Received July 18, 2017; revised September 20, 2017; accepted September 21, 2017. Funding: No extramural funding solicited or used for this work. Address correspondence to: M.S.D. e-mail: [email protected] © 2017 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.acra.2017.09.015
to the patient” (1). Similarly, The Joint Commission has prioritized effective communication as a national Patient Safety Goal (2), and requires that critical, urgent, and unexpected findings be communicated directly to the referring provider in a closed-loop fashion. Together, these establish a clear practice standard that requires certain non-routine test results be communicated directly. However, there is a “gray area” in which a radiology test result could arguably be delivered electronically rather than by phone, or by open- rather than closed-loop communication. With the ever-rising volume of radiologic testing, this equipoise occurs on a daily basis, and is a source of anxiety and frustration for radiologists. When confronted with this situation, radiologists are often torn between a medico-legal pressure to communicate, an uncertainty about the relevance of the finding in question, competing pressures that demand they continue their other work, and a feeling that the recipient of their message may be irritated at the interruption—particularly if asked to call the radiologist back. 1
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This is especially true overnight, when on-call radiologists and their referring providers are doing work at an accelerated pace in a higher acuity environment, and referring providers may be less available to receive direct communication. Given these competing priorities, we wanted to explore the sentiments of both radiology and referring provider residents with respect to the delivery and receipt of directly communicated radiology test results. It was our hope this would better inform the decision-making process of radiologists caught in the balancing act of whether and how to communicate radiology findings. Resident providers were targeted because they were perceived to be most familiar with the pressures of on-call work, and are poised to become the next generation of attending physicians. Our purpose was to determine the preferences of radiology and referring provider residents regarding direct communication of radiology test results.
METHODS This Health Insurance Portability and Accountability Actcompliant prospective quality improvement effort was “not regulated” by the host institutional review board (ie, exempt from institutional review board oversight). No protected health information was collected or analyzed. No extramural funding was used.
Subjects
Anonymous surveys were delivered electronically through a Health Insurance Portability and Accountability Act-compliant anonymous online platform (Qualtrics.com) to 43 diagnostic radiology residents and 364 residents from the emergency medicine, surgery, and internal medicine residencies at our quaternary care institution. Surgical residents were from the following residency programs: general surgery, vascular surgery, plastic surgery, cardiothoracic surgery, oral and maxillofacial surgery, otolaryngology, and urology. Surveys were sent over a 3-day period in December 2016. Respondents were encouraged to respond by being informed that the results may be used to influence local radiologist practice patterns. There were two similarly themed surveys— one for the radiology residents and one for the referring providers—reflecting their different roles in the delivery and receipt of radiology test results. Surveys focused on the frequency, indication, clinical utility, and methods of direct communication of radiology test results. Internal medicine residents were asked two additional questions regarding receipt of non-emergent radiology results for examinations performed on outpatients. In addition to their current opinions, radiology residents also were asked specifically about their experience serving as referring providers during their intern year. Free-text commentary was solicited from referring providers about the effect of direct communication on daily work. The surveys are provided in Appendix A, and the free-text responses are provided in Appendix B. 2
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Local Communications Policy
It is the local policy at our institution for radiologists to directly communicate to a member of the treatment team in a closed-loop fashion any of the following types of radiologic findings: critical, urgent, unexpected, medically significant change from a resident preliminary report. This most commonly involves a page with a note to call the radiologist back at a specified phone number. For inpatients, a “first contact” for the care team is listed in our electronic medical record system (Epic, Verona, WI). For emergency department patients, the ordering provider includes in the radiology order a call-back number of a portable phone they carry during their shift for radiologists to call directly. On call, radiology residents dictate and sign preliminary results using electronic dictation software (Powerscribe 360, Nuance Communications, Burlington, MA). The preliminary result is sent to the radiology chart review section of the electronic medical record system and is immediately visible to the treatment teams. For time-sensitive findings that are anticipated to have an immediate effect on patient care, it is policy to discuss the results verbally, which is usually by phone and may be in person. For other findings that need non-emergent communication, residents are encouraged to use the internal messaging system integrated into the electronic medical record system. For context, out of 555,805 finalized radiology reports generated at our institution over the 1-year period from October 2015 to September 2016, the proportion of reports with documented communication using our standardized internal templates was 15.9% (88,295 of 555,805). This included 12.4% (69,186 of 555,805) flagged “routine,” 2.2% (12,203 of 555,805) flagged “unexpected,” 0.7% (3987 of 555,805) flagged “urgent,” and 0.5% (2919 of 555,805) flagged “critical.” This is an underestimation of the total number of communications because it reflects only those that used the standardized templates.
Data Analysis
The type of practice at which each of the radiology residents did their preliminary or transitional year before entering radiology residency was recorded. Descriptive statistics (proportions) were calculated. Proportions were compared between specialties to chi-square or Fisher exact test. P < .05 was considered significant for hypothesis testing.
RESULTS The response rates were 86% (37 of 43) for radiology residents and 41% (151 of 364) for referring resident providers (emergency medicine: 48% [32 of 67]; surgery: 34% [45 of 134]; internal medicine: 45% [74 of 163]), with representation from all post-graduate year levels for all specialties (Table 1). Most (79%) radiology residents had done their preliminary or transitional year training at a community hospital (n = 31)
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TABLE 1. Respondent Training Program and Post-Graduate Year (pgy) Level Residency and Training Level Diagnostic Radiology Invited Participated Post-graduate year 2 Post-graduate year 3 Post-graduate year 4 Post-graduate year 5 Emergency Medicine Invited Participated Post-graduate year 1 Post-graduate year 2 Post-graduate year 3 Post-graduate year 4+ Surgery Invited Participated Post-graduate year 1 Post-graduate year 2 Post-graduate year 3 Post-graduate year 4+ Internal Medicine Invited Participated Post-graduate year 1 Post-graduate year 2 Post-graduate year 3 Post-graduate year 4+
Data 43 37 24% (9/37) 24% (9/37) 27% (10/37) 24% (9/37) 67 32 25% (8/32) 28% (9/32) 25% (8/32) 22% (7/32) 134 45 24% (11/45) 18% (8/45) 11% (5/45) 47% (21/45) 163 74 38% (28/74) 30% (22/74) 26% (19/74) 7% (5/74)
or hybrid academic practice (n = 3). None did so at the study institution. There were differences in perception between radiology residents and referring resident providers regarding the need, frequency, and value of direct radiologist communication (Tables 2–3). In general, radiology residents were more likely to consider their communications to be excessive or of minimal value compared to the referring resident providers who received them (Tables 2–3). Approximately half of radiology residents (49% [18 of 37]) thought the frequency of direct verbal communication was excessive, and none (0 of 37) thought more communication was needed (Table 2). In contrast, only 1.3% (2 of 151; P < .001) of referring providers felt the frequency was excessive, and 24% (36 of 151; P < .001) desired more (Table 3). The majority (66% [100 of 151]) of referring providers felt phone calls from radiologists often or always added value beyond a timely radiology report compared to only 41% (15 of 37) of radiology residents (P = .005). Interestingly, radiology residents were likely to remember not being phoned by radiologists during their intern year when they were functioning as referring providers (Table 2) (ie, a time in which they were not functioning as practicing radiologists), which was in contrast to the high frequency reported by referring resident providers (Table 3). More than half (54% [20 of 37])
of radiology residents stated that they anticipated communicating less often when they become attending practitioners. The majority of referring providers (83% [125 of 151]) preferred to receive a phone call about both emergent and nonemergent unexpected findings (Tables 3–4), with a minority stating they wished to be phoned only if the finding was emergent (Table 3). Of the 11 specific diagnoses we interrogated (Table 4), those that referring providers most strongly wished to be phoned directly about were acute stroke (91%–94%) and aortic rupture (89%–100%) (Table 1); interestingly, a small minority of referring providers wished not to be contacted by phone about anything, even an aortic rupture (Table 4). The diagnoses with the least preference for direct phone communication were pneumonia (19%–28%), acute fracture (27%– 49%), and obstructing urinary calculus (31%–46%) (Table 4). Most internal medicine providers (59% [44 of 74]) felt it is in part the radiologist’s responsibility to call the referring provider regarding non-emergent abnormal findings in outpatients (Table 3), although a large minority (41% [30 of 74]) stated they assumed full responsibility for looking up the results of the outpatient tests they ordered and did not expect the radiologist to notify them (Table 3). For outpatients with nonemergent unexpected findings, most providers (90% [64 of 71]) prefer written communication (ie, either in the radiology report or by electronic messaging) rather than a phone call (Table 3). DISCUSSION The importance of effective and appropriate radiologist-toprovider communication is multifold. Misdiagnosis and delayed diagnosis are common major causes of health care-associated morbidity and mortality (3–6), and are exacerbated by a failure to communicate (6). Delays in communication contribute to delayed diagnosis (6), which in turn delays effective and appropriate treatment (6). In addition, failure to communicate is a common source of liability for practicing radiologists (7,8). Although radiologists may feel internal and external pressure to avoid direct communication, and a tendency to minimize the importance of the communication they provide, our results demonstrate that referring providers in general find radiologist input to be valuable and worthwhile, and are much more likely than radiologists to feel that direct verbal communication is important, even for non-emergent unexpected results. Although we did not study the reasons behind why radiology residents prefer to avoid communication, we offer some speculative explanations. Radiologists may be more likely anti-social, afraid of confrontation, too busy, or reluctant to expose themselves to criticism. If the literature supporting clear lines of direct communication is not compelling (3–8), our data should reassure radiologists that the recipients of their communications in general welcome them and do not consider them a nuisance. Other studies have analyzed the usefulness of radiologist communication. Siewert et al. (9) performed a 10-year retrospective review of 380 communication errors and found 3
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TABLE 2. Radiology Resident Responses (n = 37 Respondents) Question
Diagnostic Radiology
During your intern year, how often did you get a phone call from a radiologist regarding abnormal radiology test results? Never Rarely (ie, only a couple times during the year) On occasion (ie, a couple times a month) Frequently (ie, a couple times a week) Very frequently (ie, daily) During your intern year, how often did you get a phone call from a radiologist regarding a study protocol? Never Rarely (ie, only a couple times during the year) On occasion (ie, a couple times a month) Frequently (ie, a couple times a week) Very frequently (ie, daily) As a department, what do you think about the frequency of our communication of test results directly to clinicians? Too much Appropriate Too infrequent Do you sometimes contact clinicians with radiology results despite knowing they are aware of the findings? Yes, often Yes, infrequently No Don't know, I never check the patient's chart to see if they're aware In your future practice (ie, as an attending), how frequently do you anticipate directly communicating findings compared to now? Less likely About the same More likely How often do you think communicating abnormal test results directly to clinicians adds anything valuable beyond a timely radiology report? Never Rarely On occasion Often Always
that errors in results communication were the most common cause of radiology communication errors (48%), with 25% of these having a major impact on patient care. Dickerson et al. (10) prospectively studied the impact of in-person communication between radiologists and acute care surgeons, and measured whether that interaction affected patient care beyond the printed final radiology report. Out of 100 subjects, they found that direct communication changed attending surgeon impression in 43% and changed medical or surgical planning in 43%; interestingly, these 43% were not entirely overlapping. The authors concluded that in-person collaboration affected care by promoting “a shared mental model that facilitates the exchange of complex information” (10). Given that the work of a diagnostic radiologist is fundamentally the translation of imaging data into actionable information (11,12), the value of a radiologist is inextricable from their ability to effectively communicate. An expert radiologist who cannot or does not communicate is an ineffective radiologist. 4
43% (16/37) 35% (13/37) 16% (6/37) 3% (1/37) 3% (1/37) 73% (27/37) 14% (5/37) 3% (1/37) 11% (4/37) 0% (0/37)
49% (18/37) 51% (19/37) 0% (0/37) 60% (22/37) 24% (9/37) 8% (3/37) 8% (3/37)
54% (20/37) 43% (16/37) 3% (1/37)
0% (0/37) 5% (2/37) 54% (20/37) 38% (14/37) 3% (1/37)
One of the paradoxical findings from our data was that radiology residents were very likely to remember not being contacted by radiologists during their intern year, which stood in contrast to the frequency of radiologist communication reported by our referring resident providers. This may be because the intern training of most of the radiology residents was often at a community hospital staffed by private practice radiologists, who may have had a different practice paradigm than the academic setting that was the focus of this investigation. Given that approximately 70% of our radiology residents end up in private practice after residency, this may in part account for the perception among more than half (54% [20 of 37]) that they would communicate less with referring providers after they graduated. We would like to reinforce that they should continue to communicate in practice! Our results have limitations. The survey was administered to resident radiologists and referring providers at a single academic institution. Communication is prioritized in our
Question
Emergency Medicine
Surgery
* Only asked of internal medicine residents. Not all respondents answered every question.
Combined
1% (1/74) 4% (3/74) 45% (33/74) 47% (35/74) 3% (2/74)
1% (2/151) 9% (13/151) 36% (54/151) 39% (59/151) 15% (23/151)
1% (1/74) 28% (21/74) 59% (44/74) 9% (7/74) 1% (1/74)
1% (2/151) 27% (41/151) 52% (78/151) 16% (24/151) 4% (6/151)
1% (1/74) 74% (55/74) 24% (18/74)
1% (2/151) 75% (113/151) 24% (36/151)
1% (1/74) 7% (5/74) 22% (16/74) 55% (41/74) 15% (11/74)
1% (1/151) 7% (10/151) 26% (40/151) 54% (82/151) 12% (18/151)
14% (10/74) 84% (62/74) 3% (2/74) 0% (0/74)
11% (16/151) 83% (125/151) 5% (7/151) 0% (0/151)
27% (19/71) 63% (45/71) 10% (7/71)
— — —
41% (30/74) 59% (44/74
— —
0% (0/74)
—
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How often do you get a phone call from a radiologist regarding abnormal test results? Never 0% (0/32) 2% (1/45) Rarely (ie, only a couple times during the year) 0% (0/32) 22% (10/45) On occasion (ie, a couple times a month) 3% (1/32) 44% (20/45) Frequently (ie, a couple times a week) 34% (11/32) 29% (13/45) Very frequently (ie, daily) 63% (20/32) 2% (1/45) How often do you get a phone call from a radiologist regarding a study protocol (ie, type of study, contrast issues)? Never 0% (0/32) 2% (1/45) Rarely (ie, only a couple times during the year) 6% (2/32) 40% (18/45) On occasion (ie, a couple times a month) 38% (12/32) 49% (22/45) Frequently (ie, a couple times a week) 44% (14/32) 7% (3/45) Very frequently (ie, daily) 13% (4/32) 2% (1/45) What do you think about the frequency of phone calls regarding test results from radiologists? Too frequent, they need to cut back 3% (1/32) 0% (0/45) Appropriate 75% (24/32) 76% (34/45) Not enough, they're helpful and I would prefer more phone calls 22% (7/32) 24% (11/45) How often does a phone call from a radiologist add anything valuable beyond the radiology report? Never 0% (0/32) 0% (0/45) Rarely 1% (1/32) 9% (4/45) On occasion 31% (10/32) 31% (14/45) Often 63% (20/32) 47% (21/45) Always 3% (1/32) 13% (6/45) If radiology reports are available in a timely manner, what would be your preference? Receive a phone call only about emergent findings 16% (5/32) 9% (4/45) Receive a phone call about emergent and also non-emergent abnormal or unexpected findings 81% (26/32) 82% (37/45) Receive a page when the report is available 3% (1/32) 9% (4/45) Not receive a phone call or a page about any findings, I would prefer to check the report myself according to my 0% (0/32) 0% (0/45) own workflow *What is your preference for communication of non-emergent abnormal radiology results specifically for outpatients? I don't want to be interrupted about it, I would prefer to review the results myself I prefer a message via the internal electronic medical record messaging system or via my pager I prefer a phone call *Regarding non-emergent radiology results, which of the following do you most agree with? It is my responsibility to follow-up on results for a study I ordered, not the radiologists' responsibility to call about abnormal results. It is primarily my responsibility to follow-up on results for a study I ordered, but it is also the radiologist's responsibility to call about abnormal results. It is not primarily my responsibility to follow-up on results for a study I ordered; it is primarily the radiologist's responsibility to call about abnormal results.
Internal Medicine
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TABLE 3. Referring Resident Provider Responses (n = 32 Emergency Medicine, n = 45 Surgery, n = 74 Internal Medicine).
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TABLE 4. Diagnosis-specific Preferences for Method of Notification by Referring Provider Respondents (n = 32 Emergency Medicine [EM], n = 45 Surgery [S], n = 74 Internal Medicine [IM]) Discussion by Phone (Closed-loop Communication) Radiology Diagnosis Acute fracture Acute appendicitis Pneumonia Malpositioned tube or catheter Acute stroke New mass or suspected cancer Pulmonary embolism Aortic rupture Retroperitoneal hemorrhage without active bleeding Small bowel obstruction Obstructing urinary calculus
Pager Notification (Call Back Not Required)
Do Not Contact
EM
S
IM
EM
S
IM
EM
S
IM
47% (15) 72% (23) 28% (9) 72% (23) 94% (30) 54% (17) 78% (25) 100% (32) 69% (22)
27% (12) 44% (20) 19% (8) 52% (23) 91% (40) 42% (19) 82% (37) 91% (41) 47% (21)
49% (36) 76% (56) 18% (13) 57% (42) 92% (68) 64% (47) 80% (59) 89% (66) 64% (47)
38% (12) 25% (8) 56% (18) 22% (7) 6% (2) 41% (13) 16% (5) 0% (0) 25% (8)
61% (27) 51% (23) 65% (28) 48% (21) 9% (4) 51% (23) 18% (8) 9% (4) 49% (22)
44% (32) 20% (15) 49% (36) 38% (28) 8% (6) 34% (25) 18% (13) 9% (7) 32% (24)
16% (5) 3% (1) 16% (5) 6% (2) 0% (0) 6% (2) 6% (2) 0% (0) 6% (2)
11% (5) 4% (2) 16% (7) 0% (0) 0% (0) 7% (3) 0% (0) 0% (0) 4% (2)
7% (5) 4% (3) 34% (25) 5% (4) 0% (0) 3% (2) 3% (2) 1% (1) 4% (3)
59% (19) 44% (14)
32% (14) 31% (13)
54% (40) 46% (34)
34% (11) 50% (16)
48% (21) 52% (22)
39% (29) 45% (33)
6% (2) 6% (2)
20% (9) 17% (7)
7% (5) 9% (7)
Numbers in parentheses are N. Not all respondents answered every question. Denominators are the number of respondents within each specialty that responded to each diagnosis.
radiology department—15.9% of finalized radiology reports contain structured text indicating that some form of radiologistto-provider communication took place. Therefore, our results may not apply to community hospitals, academic hospitals with less aggressive communications policies, or attending practitioners with different knowledge or priorities. However, the methods of communication and practice patterns learned by residents form the basis for future practice, and it is plausible that our results might be similar at other sites. Although our response rate was adequate (13), it is possible that nonrespondents had different points of view that could have altered our conclusions had they participated. Finally, subtle differences in wording of the questions in our survey may have affected the responses we received. Therefore, validation of our results in separate practice settings using questions that probe similar content would be important to assure the generalizability of our findings. In conclusion, referring resident providers prefer direct communication of radiology results, even for non-urgent unexpected findings, whereas radiology residents prefer less direct communication and are more likely to consider radiologist-toprovider communication superfluous. Our results provide additional support for the notion that direct radiologist-toprovider communication is important, desired, and valuable for patient care, and highlights an opportunity for education of radiologist trainees about the value of this activity. Investigating ways to streamline communication—such as by leveraging information technology solutions (14)—is likely to be worthwhile, thought it will be important to compare the clinical and inter-personal outcomes achieved by such solutions (ie, beyond simple transactional receipt of a report) against the ideals of in-person and direct vocal communication (10) by radiologists acting as both information broker and consultant physician (15). At a time when radiologists are often 6
disconnected physically from referring providers, efforts to maximize effective and timely communication are essential elements of the value radiology brings to patient care. REFERENCES 1. ACR. Practice Parameter for Communication of Diagnostic Imaging Findings. Revised 2014. Available at: https://www.acr.org/~/media/ C5D1443C9EA4424AA12477D1AD1D927D.pdf. Accessed 5/18/2017. 2. The Joint Commission. National Patient Safety Goals. Effective: 1/1/2015. Critical Access Hospital Accreditation Program. Available at: http://www.jointcommission.org/assets/1/6/2015_NPSG_CAH.pdf. Accessed 5/18/2017. 3. Graber ML. The incidence of diagnosis error in medicine. BMJ Qual Saf 2013; 22(suppl 2):ii21–ii27. 4. Singh H, Meyer AN, Thomas EJ. The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations. BMJ Qual Saf 2014; 23:727–731. 5. Murphy DR, Singh H, Berlin L. Communication breakdown and diagnostic errors: a radiology perspective. Diagnosis 2014; 1:253–261. 6. Institute of Medicine. Improving diagnosis in health care. Washington, DC: National Academies of Sciences, Engineering, and Medicine, 2015. Available at: http://www.nationalacademies.org/hmd/Reports/2015/ Improving-Diagnosis-in-Healthcare.aspx. 7. Schwinger HN. Liability problems in radiology communications exist. ACR Bulletin 46:33. 1990 8. Berlin L. Communicating nonroutine radiologic findings to the ordering physician: will (should) information technology-assisted communication replace direct voice contact? Radiology 2015; 277:332–336. 9. Siewert B, Brook OR, Hochman M, et al. Impact of communication errors in radiology on patient care, customer satisfaction, and work-flow efficiency. AJR Am J Roentgenol 2016; 206:573–579. 10. Dickerson EC, Alam HB, Brown RK, et al. In-person communication between radiologists and acute care surgeons leads to significant alterations in surgical decision making. J Am Coll Radiol 2016; 13:943– 949. 11. Baron RL. The radiologist as interpreter and translator. Radiology 2014; 272:4–8. 12. Boland GW, Duszak R, Jr, Larson PA. Communication of actionable information. J Am Coll Radiol 2014; 11:1019–1021. 13. Nulty DD. The adequacy of response rates to online and paper surveys: what can be done? Assessment and Evaluation in Higher Education 2008; 33:301–314.
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14. Eisenberg RL, Yamada K, Yam CS, et al. Electronic messaging system for communicating important, but nonemergent, abnormal imaging results. Radiology 2010; 257:724–731. 15. Baker SR. Transmission of nonemergent critical findings: communication versus consultation. Radiology 2010; 257:609–611.
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SUPPLEMENTARY DATA Supplementary data related to this article can be found at https://doi.org/10.1016/j.acra.2017.09.015.
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