Overview

This project at an academic medical center developed an automated alert notification system for communicating critical imaging results to increase adherence to institutional policy and improve the timeliness of communication of key findings.

Organization Name

Brigham and Women’s Hospital

Organization Type

• Academic Medical Center
• Integrated healthcare system/network

National/Policy Context

• Delayed communication of critical test results can jeopardize patient safety by 1) hindering further testing or treatment, and 2) causing management errors. 
• Given these risks, the Joint Commission recognized critical test result communication as a national patient safety goal.

Local/Organizational Context

• Before this intervention was implemented, an institution-wide policy was established for communicating critical test results to prevent non-transmittal of diagnostic test results as well as to mitigate delays in communication.
  • This policy included guidelines and procedures for notifying the provider for a patient whose imaging yielded a critical result (i.e. a new or unexpected radiologic finding that demands appropriate follow-up to avoid morbidity or mortality).
  • It delineated three alert levels based on urgency: red, orange, and yellow, with each of these demanding documentation of closed-loop communication within a certain timeframe (60 minutes, 3 hours, and 15 days, respectively).
  • According to the policy, red alerts must be synchronous and interruptive (e.g. in-person or telephone conversation between radiologist and provider), while others can be asynchronous and non-interruptive. 
• After the policy was implemented, it was determined that the proportion of critical imaging results that were communicated according to the policy increased significantly.
• However, some critical results were still non-adherent to the policy, perhaps due to the burdensome process to communicate and/or workflow interruptions (e.g. paging).
• In response, the innovators developed an automated alert notification system to further streamline communication and documentation of critical test results.

Patient Population Served and Payor Information

• Medical records, particularly radiologic data, were reviewed for patients cared for at a 753-bed urban adult tertiary academic medical center.

Leadership

• Ronilda Lacson
• Luciano M. Prevedello
• Katherine P. Andriole
• Stacy D. O’Connor
• Christopher Roy
• Tejal Gandhi
• Anuj K. Dalal
• Luke Sato
• Ramin Khorasani

Funding

• The project was supported by grant R18HS019635 from the Agency for Healthcare Research & Quality as part of the Partnerships in Implementing Patient Safety II Initiative, grant T15LM007092 from the U.S. National Library of Medicine, and two grants from the Controlled Risk Insurance Company Risk Management Foundation.

Research + Planning

• Steps taken to prepare for the implementation of this project likely included:
  • Development of automated alert notification for critical results
  • Integration of alert notification for critical results with PACS (picture archiving and communication system), paging and email systems, and electronic medical record
  • Training of radiologists on how to communicate critical findings with this system, both synchronously and asynchronously 
  • Training of other providers on how the alert notification system works, particularly how to acknowledge receipt of alerts
  • Development of a system to track and audit alerts to ensure findings are acknowledged

Tools or Products Developed

• Alert Notification of Critical Results: An automated system that enables radiologists to communicate findings both synchronously and asynchronously to other providers. It also allows for those providers to acknowledge receipt of alerts from both tethered or mobile devices. 

Training

• Implementation of the project required training of radiologists on how to communicate critical findings with this system, both synchronously and asynchronously, and training of other providers on how the alert notification system works, particularly on how to acknowledge receipt of alerts. 

Tech Involved

• Desktop computer
• Electronic medical record
• Software Program

Team Members Involved

• Physicians

Workflow Steps

The below is a hypothetical example of a potential workflow. Many other examples could be used. 

• A patient has a CT scan of her chest (or other imaging) done. After the scan, she goes home. 
• At a later point in time, a radiologist reviews the CT scan, and finds a lung nodule (or other critical finding). 
• The critical finding is communicated via the automated alert notification system, which pages the primary provider (synchronous, requires very urgent attention) or sends a secure email (asynchronous, requires less urgent attention). 
• The primary provider, who was paged or emailed, acknowledges receipt of the alert from her computer or mobile device, and then views the radiology report to learn more about the critical result.
• The primary provider follows up with the patient as appropriate. 

Budget Details

The following sources of costs were estimated by the CareZooming team:

• Cost of time spent developing the alert notification system 
• Cost of time spent by IT integrating the automated alert system into the EHR, PACS, paging and email systems

Where We Are

The project has been completed.

Outcomes

• Policy Adherence: The primary outcome was the impact of the alert notification system on radiologists’ adherence to the policy mandating that providers be notified of all critical results.
  • Policy adherence increased from 91.3% of radiology reports before implementation to 95% after implementation. 
• System Adoption: The secondary outcome was the adoption of the system during the first four years after implementation. 
  • Within 18 months of implementation, 81% of all radiology reports used the alert notification system, and that figure stayed constant through the end of the measurement period. 

Future Outcomes

In the future, it would be valuable to explore whether patients should receive alerts and what impact that might have on their care.

Benefits

• Benefits of the alert notification system that are demonstrated by the data presented include increased adherence to institutional policy around communication of critical results and a new ability to communicate less urgent critical results in a non-interruptive manner (e.g. secure email instead of paging), which is less disruptive to workflows. 
• Potential benefits include improved patient safety, less delay in communication of critical results, and fewer errors resulting from delayed communication.

Unique Challenges

• Common challenges in the implementation of new clinical information systems include increased workload for clinicians and disruption of complex workflows and communication patterns. 
• Significant institutional and executive support for the policy and integration of the technology within existing physician workflows helped to navigate these challenges.

Sources

• This primer was developed by the CareZooming team based on our analysis of a research article found and accessed through public sources. Authors were able to review the contents of this primer before publication, and all requested edits have been incorporated into the primer as presented above.
• Lacson R, Prevedello LM, Andriole KP, O’Connor SD, Roy C, Gandhi T, Dalal AK,  Sato L, Khorasani R. Four-year impact of an alert notification system on closed-loop communication of critical test results. AJR Am J Roentgenol. 2014 Nov;203(5):933-8. doi: 10.2214/AJR.14.13064. PubMed PMID: 25341129; PubMed Central PMCID: PMC4426858.