After Image Import: What to Do with Referral CD Studies

With radiology studies traditionally transferred on CD, tertiary care facilities are getting inundated with data. What’s the best way to manage the CDs patients bring in? What are the liability issues with reading - or not reading - the studies? In an age where institutions are trying to reduce radiation exposure, when should you repeat a study?

These are some of the questions raised by Perry Gerard, MD and Zvi Lefkovitz, MD of Westchester Medical Center in New York, who presented an exhibit at the recent American Roentgen Ray Society annual meeting. The exhibit highlighted the medical center’s development and implementation of a policy and work flow to import outside CDs of radiology studies. It also created guidelines for which studies would be replicated in-house, and which studies would get formal dictated reports by the center’s radiology staff.

Westchester Medical Center is not alone. These issues are a common challenge to hospital radiology departments, said Vijay Rao, MD, the David C. Levin professor and chair of the department of radiology at Thomas Jefferson University Hospital. “Everybody is looking for guidance and every institution is creating its own solution. We’ve been talking about this for eons now, without a truly satisfying answer. The number of CDs coming into any tertiary facility is astronomical.”

For a major tertiary facility, many patients often arrive with completed work-ups, including radiology studies, and the referring physicians want those placed on the hospital PACS system, said Lefkovitz, director of radiology at Westchester Medical Center and chairman of radiology at New York Medical College. While initially WMC staff was only able to do this during normal weekday business hours, as part of their policy project they installed additional software in the emergency department and trained the night and weekend technologists how to upload.

Identifying, Storing and Accessing 

There are challenges to uploading, many of them technical. “Not every DICOM is a DICOM,” Rao said. “You can’t always open a CD.”

Gerard, director of nuclear medicine and radiology IT at WMC and vice-chairman of radiology at New York Medical College, said that since installing the new software, which allows staff in the ED to upload the CDs, the number of studies that failed to upload decreased significantly.

Even when the upload is simple, the images need to be tagged with a medical record number or patient identification number. Another issue is that the information technology systems may not communicate with each other.

At Jefferson, Rao said, “the outpatient EMR is not communicating with the hospital information system or the radiology information system. We are fragmented in that sense.” It requires manual labor to load the CD into the EMR, and yet more effort to bring it into PACS. They have to manually reconcile the patient identity each time.

There’s also the issue of storage: permanent or short term. Rao’s institution stores these records permanently for patients who are admitted to the hospital or will be coming in for follow-up. However if a patient is only coming in for a consult, or the physician needs them for tumor conferences or other conferences, they may store them temporarily, purging after a month. “You have to look at the cost of storing these images,” she said. “How long do you store them? It is truly an incredibly complex and difficult situation to deal with.”

Reading and Reporting: Legal Issues 

Both Rao and Lekovitz noted that the CDs usually come with no written radiology report, since the CD is burned before the report is dictated.

Each hospital needs to develop a policy for how to handle reading the studies. For WMC, the referring physician has the option to just have the images placed on PACS for comparison. Otherwise, the radiologists will dictate a formal report. Lefkovitz said he believes they bill the patient for the report, but does not know how much is recovered from that. “The purpose of this is not as a moneymaker,” he said, but to enhance the efficiency of care and to provide good service to the referring physicians.

“We’re providing better care and the referring physicians are looking at this very favorably, even if there’s no monetary value I can pinpoint,” he said. “There’s a halo effect. Long term we’ll see more patients coming here, partly because of the added value we provide.”

Rao noted that physicians at tertiary centers tend to trust their colleagues, asking them to review the prior radiology studies. She said that this puts the radiologists in an interesting position. The radiologists don’t have enough patient information or comparison studies, so they feel at a disadvantage to give a formal report. Yet, curbside consults are also problematic, because the radiologist is legally responsible for what is said, even if it’s not in writing. “Someone is now integrating your verbal impression and they can misconstrue what is said,” she said.

Jefferson did a pilot program, Rao said, giving formal reports on some imported studies. “The amount of time it takes to give a formal report is time intensive,” she said. They submit an insurance bill for those, but the collection rate is only 20 percent. “Most of the insurance won’t pay for a second read or consultation,” she said. Jefferson does not bill the patient for these uncollected insurance billings.

The question arises as to whether to expand the practice of giving formal reports, even without payment, since the formal report provides more legal protection, said Rao. “Is it worth the time? No,” she said. They’re still doing a lot of informal consults. “That’s the price you pay for being subspecialized. Clinicians come to the reading room all the time. They’re our colleagues, so you look at it and give your opinion. Yes, you are taking legal responsibility because they go back and write it in the chart that you reviewed it.”

As for legal implications, Lefkovitz said they consulted the hospital’s legal team when formulating the policy. “The patient is coming here anyway, and as an inpatient, we’re covered under that,” he said.

Other legal issues and obligations arise if the reviewing radiologist has a different opinion than the first one, said Leonard Berlin, MD, professor of radiology at Rush University and University of Illinois at Chicago, and author of Malpractice Issues in Radiology. If there’s a difference in opinion, the reviewing radiologist should dictate that opinion into a report, then contact the referring physician directly about the disagreement, he said.

There’s up to a 25 percent rate of disagreement on study interpretations, Berlin said. “If they disagree with the interpretation, obviously then it behooves the new radiologist to dictate a new report.”The new review should be given the current date, and should not condemn or criticize the previous report, but mention there’s a disagreement in the results seen. “Be effectual, and not judgmental,” he added.

Repeating Studies 

When patients are seen in a tertiary center’s ED, they often come with studies already done. “Right now the easy way out is to repeat everything in the emergency department for transfer patients,” Rao said. Jefferson is beginning a pilot project this summer to look at the transfer patients coming through the ED - and the CDs coming with them. Since trauma patients have been radiated “head to toe,” she said, they’ll upload those studies to the system and give a formal report. If there are parts of the body where the imaging is inadequate, they’ll do targeted studies, which will reduce the radiation, avoid unnecessary utilization of hospital resources, and hopefully expedite the treatment process and keep resources open for other patients. Rao cited a Radiology study published last summer, where Brigham and Women’s Hospital was able to reduce ED imaging by 17 percent by transferring outside CDs onto their PACS.

“All the hospitals are looking toward radiology leadership to reduce unnecessary utilization,” she said.

Lefkovitz agreed that having a policy in place to avoid additional imaging is valuable. He said they found that about 85 percent to 90 percent of patients transferred into the WMC ED with recently completed imaging do not require repeated scans on admission day. “Many are very sick, and days later they may get a follow-up MRI and CT,” he said, but they’ve found a significant savings in cost, radiation dose, contrast administration and efficiency.

WMC’s policy is to formally read CTs and X-ray studies, which involve radiation and/or contrast administration, plus MRIs. They will redo ultrasound studies, because they’re tech-dependent and results can vary. “You could get skewed information or misinformation on ultrasound,” Lefkovitz said.

Rao noted creating a hospital policy on CD import is important. “We want to create some kind of a policy to review these images and give a formal report so we can avoid repeating the studies,” she said. “because that’s the right thing for the patient.”