Documentation of Radiology Results Distribution

Transcription

1 University of Michigan Hospitals Department of Radiology Documentation of Radiology Results Distribution Prepared for: James Aidridge Administrative Director Department of Radiology By: Debbie Carlisi Valerie Hamilton Katie McDonald Management Systems Department January 2, 1993

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3 Executive Summary Management Systems was asked by the Radiology department to conduct a detailed study, with flowcharting and documentation of the process by which Radiology results are printed, delivered, posted and reviewed. The purpose was to define the process, identify problem areas and determine the usefulness of the Radiology report hard copy. Radiology services inpatient units, outpatient clinics, satellite clinics and outside referring physicians thus samples from each of these areas were investigated. The methodology used in this study included interviewing members of the Radiology department and staff members in each unit or clinic mentioned above. Each process was then flowcharted and surveys were attached to Radiology report hard copies for outpatient and satellite clinics in order to determine the times for steps in the routing process. The collected data was then analyzed so that problem areas could be identified. Finally, physicians were interviewed and asked to fill out surveys in order to ascertain the most useful methods of receiving Radiology results. The following sections describe the results and recommendations for inpatient, outpatient, satellite clinics, outside referring physicians, and the medical record copy of Radiology reports. Inpatient Units Radiology sends all reports for discharged patient to Inpatient units which then must send them to the Medical Record Room. We recommend that Radiology send these reports directly to the Medical Record Room. Approximately 7% of the time, reports for 4D North or 4D South are sent to one location or the other. We recommend emphasizing accurately sorting and sending reports. The procedure to print time is quite variable with a range from to 6 days. We recommend eliminating the variability and reducing the average number of days for the reports to be printed. Physicians look at the actual x-ray 52% of the time, but sometimes they are unable to interpret Radiology results. We recommend having an attending Radiologist available at all times to

4 Satellite Clinics Some outpatient clinics have time delays in receiving Radiology Outpatient Clinics use the different methods for obtaining Radiology results. physicians must be informed of how to reach the Radiologist and how to Records Room. We recommend sending reports directly to the clinic. example track how long it takes the Radiologists to sign the reports. studying the procedure to printing process in greater detail, for recommend investigating the procedure to printing process in greater obtain Radiology results, and it is difficult to log on RIS and Pathnet. detail. recommend always listing the last name before the first name on the Hard copy reports are not returning in a timely manner. We working days after the procedure to be printed. We recommend Physicians are not familiar with all of the available methods to Confusion often exists about the name of the patient. We The same Radiologist signed 22 of 25 reports that took over 5 Inform the physicians of all the methods available, instruct them how assist the physicians in reading the exams. Additionally, the reports as a result of reports first being sent to the Ambulatory the reports sent to the Northeast Clinic were for physicians that did entered into the computer. 1. Look at the process in which the patient information is being from exams taken at the clinic (1 3.2 vs. 7.1 working days). We Several reports are returning to the incorrect clinic (e.g. 1 8% of recommend investigating the process from procedure until printing to exam is completed at the hospital is much greater than those reports The average number of working days for reports to return after an to access them, and make accessing them easier. report. determine why these delays occur. not work there). In addition, 1 3.2% of the reports did not return to the Northeast and Northville Clinics at all. We recommend six actions to address this problem.

5 2. Standardize referral forms OR eliminate referral forms and allow the satellite clinics to enter the patient information at the site. 3. Have clinics print out their own reports on site or use automated facsimile transmission to distribute reports. 4. Have clinics keep one copy of the referral form and monitor return timeliness and accuracy. 5. Review physicians practicing locations for accuracy and update as necessary. 6. Add the full name of the clinic and the physician code to the hard copy report. Outside Referring Physicians Often there is incorrect or missing information regarding physician s names and addresses, and whether they are an inside or outside physician. We recommend emphasizing the importance of entering complete and accurate data to the clerical staff. More than one doctor number exists for the same physician. We recommend verifying that a number has not been assigned to a physician before assigning a new doctor number. It is difficult for patients to check out films so that the outside referring physician can review them. We recommend allowing outside referring physicians to sign out their own patients films directly. Outside referring physicians call Radiology directly for results. We recommend informing and instructing physicians to use RTAS for a verbal dictation. Reports take longer than expected by outside referring physicians. We recommend using automated facsimile transmission as a way of report distribution. Medical Record Copy Physicians are looking in the patient s medical record for a report that is filed in an outguide. We recommend informing outpatient clinics that if a medical record was transferred to them from a location other than the Medical Records Room, they should call to see if there are any loose sheets in the patient s outguide.

6 Table of Contents Introduction 1 Purpose 1 Project Scope 2 Discussion Physician Copy Inpatient Units Flowcharting: Post-Printing Process 3 Procedure to Printing Times 7 Reports Sent to Incorrect Location 9 Methods Used by Physicians to ObtaIn Rad. Results Outpatient Units Flowcharting: Post-Printing Process 14 Procedure to Printing Times 22 Methods Used by Physicians to Obtain Rad. Results Satellite Clinics Flowcharting: Post-Printing Process 3 Procedure to Printing and Overall Turnaround Times.. 4 Date of Procedure or Date Films Sent In to Date Received by Clinic 42 Methods Used by Physicians to Obtain Rad. Results Outside Referring Physicians Flowcharting: Post-Printing Process 65 Procedure tâ Printirg Times 72 Methods Used by Physicians to Obtain Rad. Results Overall Procedure to Printing Times 75 Methods Used by Physicians to Obtain Rad. Results Medical Record Copy Flowcharting: Post-Printing Process 79 Procedure to File Time 83 Action Plan 85

7 INTRODUCTION The Radiology Department of the University of Michigan Hospitals is currently searching for ways to improve the routing process of Radiology reports. This project was prompted by numerous complaints that have been received by Radiology concerning time delays in receiving Radiology reports. In the past, studies have been conducted to determine if the delays are caused within the department. To address intradepartmental delays, more transcriptionists have been hired and more frequent batch printing has been suggested, however, the computer system is unable to print at the recommended times. Since Radiology is unfamiliar with the path of the printed copy once it leaves the department, the Management Systems department conducted a detailed study analyzing this process. This report discusses several issues concerning the radiology report routing procedure. It separately addresses concerns regarding inpatient clinics, outpatient clinics, satellite clinics, and referring physicians. Each section includes a detailed description of the methodology, results, conclusions, and recommendations. The postprinting process, the times from procedure to review of the hard copy report, and the methods used by physicians to obtain radiology results are discussed for all four sections. The outpatient section also evaluates a concern with the reports being sent to the incorrect location. The satellite clinic section also discusses the time for reports to be received by a clinic after an exam is taken at the hospital or after the patient s films are sent in by the ordering clinic. Overall comparisons are made at the end as well as a discussion of the and procedure to file time for the medical record copy. PURPOSE The purpose of this project was to conduct a detailed study, with flowcharting and documentation of the process by which Radiology results are printed, delivered, posted, and reviewed by the physician. The purpose was also to determine the usefulness of the Radiology 1

8 report hard copy. The goal was to define the process and identify problem areas. PROJECT SCOPE The Department of Radiology services inpatient units, outpatient units, satellite clinics, and community physicians. Samples from each of these areas were investigated and included the following: Inpatient units in University Hospital: 7D - Internal Medicine Intensive Care Unit 4D North - Thoracic Intensive Care Unit 4D South - Neurosurgery/Neurology Intensive Care Unit 6C - Pulmonary General Care Unit Outpatient units in Taubman Center: Neurology Rheumatology/Arthritis in Internal Medicine Satellite clinics: Briarwood Family Practice University of Michigan Medical Group, Briarwood Campus Northeast Clinic Northville Clinic Brighton Clinic Plymouth Clinic Community physician clinic: Michigan Head Pain and Neurological Institute The scope of this project included: the routing process of the reports after they were printed, the time for each step in the process, and the other methods by which physicians receive results. C 2

9 Inpatient Units Inpatient Clinics Flowcharting: Post-Printing Process Methodology Interviews were conducted in order to determine the report routing process for the inpatient units. Members of the Radiology Department described the steps involved in printing, sorting and sending the reports to the units. Members of the clerical staff on the inpatient units described the steps inreceiving the reports and posting them to the patients charts. After the steps were identified, a flowchart of the process was constructed. See Flowchart 1, pages 5-6. Because the inpatient routing process takes only about an hour, a time study to determine how long each step takes was not performed. According to the clerks of inpatient units,reports are posted to the patient s chart on the same day they are printed (provided the report is initially sent to the correct inpatient unit). Results All inpatient reports are printed in the evening around 7: pm, sorted, and immediately sent to the appropriate inpatient units via the tube system. When the clerk in the unit receives the reports he/she checks to see if the patient is still on that unit. If the patient is on the unit, the clerk posts the report to the patient s chart. If the patient is not on the unit, the clerk looks up the patient in the Admit Discharge Transfer (ADT) Computer System to determine if the patient is still in the hospital or if he/she has been discharged. If the clerk finds the current location for the patient, the report is forwarded via the tube system. If the patient has been discharged from the hospital, then the report is sent to the Medical Record Room (MRDQ) and it will be posted to the chart at this location. Notice, in this case, the reports are first 3

10 inpatient Units sent to a unit and then resent to the MRDQ. This is time consuming and inefficient. Whenever reports are sent to a wrong location delays occur. Two main causes are: incorrect location information printed on the report, or a sorting error occuring in Radiology. The location information printed on the report could be wrong if entered incorrectly at admissions, or if patient movement (including discharge was not updated). Refer to the section on Reports Sent to Incorrect Location. Conclusions The process for sending the reports to inpatient units is relatively straight forward and simple however improvements can be made. The errors that occur in entering the location of the patient at the time of the procedure and in sorting and sending reports should be eliminated. The process of sending reports to units after the patient has been discharged is unnecessary and should be terminated. Recommendations In order eliminate reports from being sent to incorrect locations, emphasis should be placed on entering the correct location of the patient and on accurately sorting and sending the reports. The reports for patients that have been discharged should be sent directly to the MRDQ. C. 4

11 fl 5 Reports Printed computer entered into instructions removed from Reports Sorted by Reports Sent to Printed Reports Report in Unit Room Clerk Receives System Unit Unit Via Tube printer in Records Printing Flowchart 1 Report Routing Process for Inpatient Units Inpatient Units

12 inpatient Units Clerk checks if patient is in Unit I No Clerk looks up Patient in ADT computer system Yes Clerk posts report to Patient Chart ientin Hospital No Yes C Clerk sends report tomrdq Note: See Medical Record Copy Flowchart for Details r Report is posted to chart C 6

13 Methodology procedure and printing was calculated. This calculation can give a procedure to print time equal to zero if the report is printed on the same day the exam is taken. Results 2.4 days with a standard deviation of 1.7 days, see Figure 1, page 8. between procedure and printing. Including outliers results in a mean Conclusions them. This mean and standard deviation was calculated after eliminating six From procedure to printing, inpatient reports took an average of Reports printed for all inpatient units on December 1 1 were analyzed to determine the average time between the day the procedure was done and day the report was printed. There were 272 reports that Secondly, identify areas in which normal delays occur and improve three reports were MRI exams, and two reports had Dr. Albert Seow as a greater detail. There are two issues that should be addressed, the first that is 3.1 days with standard deviation of 5.7 days. Of the six The outliers included reports with 14, 1 5, 2, 47, 49, and 6 days Radiology house officer. Radiology should study the procedure to printing process in Recommendations The results show that 73% of the Radiology reports are currently being printed within three days, and 89% are being printed within four were studied. The total number of days (nt working days) between outliers. The range of this sample was between and 6 days. outliers, three reports had Dr. John Hald as the attending radiologist, days. However, six reports took more than 1 days. Procedure to Printing Times Inpatient Units is determine what causes outliers and eliminate this variability. 7

14 -D CD C c-f (A Figure 1 7H Number.of Reports vs. Number of Days from Procedure to Printing 34.6% 6.7% 68 3 (I) a) cc c z % 89.% % 13 5 No. of Days 95.2% % % 97.8% I I I I

15 Inpatient Units Reports Sent to Incorrect Location Methodology In order to determine how often reports are sent to an incorrect inpatient unit, members of the clerical staff in three inpatient units collected data for a one week period. Sue McMahon in 6C collected data for five days between December 3 and December 1 6. Kathy Crosby in 4D-South collected data for five days between October 23 and November 2. Kate Baker in 4D-North collected data for five days between October 23 and November 9. The data contained the following information: 1. The total number of reports received that day 2. The number of reports with patients still on the unit 3. For the reports with the patient not on the unit: a. The patient number b. The date the exam was taken c. The date the patient was transferred or discharged d. The new patient location Results The data contained information for 27 reports that were received by the clerks.. Of these reports, 33% (68 out of 27) were initially sent to an incorrect location. An incorrect location is a unit the patient is not currently a resident of.. Of the. 68.reports sent to an incorrect location, 46 repàrs fdr4-dwere all sent to either 4D-North or 4D-South. For example, on some days all of the reports for 4D-North and 4D-South were sent to 4D-North. When this occurs, the clerk in 4D-North must walk the reports over to 4D-South which is the unit next door. This happened in 7 out of the 1 days that we studied these two units. Another large component of the reports sent to an incorrect location is the reports for patients that have been discharged from that unit. Out of the 68 reports sent to an incorrect location, 1 9 reports were for patients who had been discharged. A significant percentage of reports, 1 2.5% for unit 6C, and 7.4% for units 4D-North and 4D-South,.9

16 Inpatient Units were for patients who had been discharged (see Figure 2, page 1 1). When the patient has been discharged, the unit no longer has the patient s chart that the report must be attached to, thus the report is then sent to the Medical Record Room. This process is inefficient because reports for discharged patients are sent to all of the inpatient units throughout the hospital and then sent to the Medical Record Room. This occurs every day because approximately 9.2% of all printed inpatient reports are for discharged patients. ( Conclusions The Radiology Department sends 9.2% of all inpatient reports to units after the patient has been discharged. Additionally, 7% of the time all reports for units 4D-North and 4D-South are sent to one unit or the other. Recommendations More attention should be given to correctly sorting the reports for 4D-North and 4D-South so that they are not only sent to one unit or the other. This will eliminate the need for clerks having to walk them over to the appropriate unit. Radiology reports for patients who have been discharged should be sent directly to the Medical Record Room. This can be done by changing a portion of the code in the Admit Discharge Transfer Computer System. Specifically, the system should update the patient location field in order to denote that the patient has been discharged. By doing this, all reports for discharged patients will be printed in a batch and then sent to the Medical Record Room together. William Nye, Administrator for Clinical Support Services in the Department of Radiology is aware of this solution and how to implement it. 1

17 D f-f CD rt C f-f U, FigUre 2 % Inpatient Reports SE nt to UnIt after Patient Discharç ed 12.5%. / I / ci) ci) U- 14%- 1%- / U / c of U / 7.4% (_) / :_ / (1/ LI 6C 4D-N/s I mit

18 6. Radiologist calls ordering physician 7. Look at X-Ray 5. Read hard copy 6. Radiologist Calls Phys Call Radiology Department 3. Log on to RIS 4. Log on to Pathnet 2. Call Radiology Dept. 3. Log on to RIS 7. Look at X-Ray defined by the Radiology Department include the following: The seven methods available for obtaining Radiology results Table 1. Methods of Obtaining Radiology results. There were twelve physicians that participated by filling out the survey. The methods used and the percentage of the time each method 4. Log on to Pathnet 1 Methods another method before reading the hard copy. Methodology Results C Methods used by Physicians to Obtain Radiology Results C Inpatient Units 1. Listen to RTAS digital dictation 5. Read Hard Copy A survey was given to physicians that work in the following is used is shown in Table Listen to RTAS 52 C Percentage Used the hard copy refers to only the reports that had not been reviewed by inpatient units: 4D-North, 4D-South, 6C, and 7D. In this survey, reading

19 Inpatient Units As illustrated above, looking at the actual X-Ray is by far the most popular method of obtaining Radiology reports. The only problem physicians mentioned regarding reading the X-Ray themselves was that sometimes they had questions and needed help interpreting. Unfortunately they said that often there was not a Radiologist available to help them and this was very inconvenient and time consuming. Listening to the RTAS digital dictation system, logging on to RIS, and logging on to Pathnet are the next most frequently used methods. The problem that was expressed with RTAS, Pathnet and RIS was the time lag after the exam is taken before the information is available on these systems. The physicians explained that in some cases an interpretation is needed quickly and these methods are less useful. Conclusions Timeliness is the most important concern for the physicians working in the inpatient Units. The quickest method is looking at the actual X-Ray, thus, this is the most frequently used method. Recommendations In order to adequately serve the physicians on the inpatient units, an attending Radiologist should be available at all times. in addition the physicians should know how to reach this Radiologist. The Radiology Department could distribute a letter to all inpatient physicians listing the. telephone and beeper numbers for the Radiologist so the physicians can easily reach him/her. 13

20 Outpatient Clinics Outpatient Clinics Flowcharting: Post-Printing Process Methodology In order to determine the routing procedure for outpatient reports, interviews were conducted to identify each step of the post printing process. For the Arthritis Clinic, this information was given by Mary Davidson of Radiology, a clerk in the Ambulatory Records Room on third floor Taubman, Liz Marshall and Elizabeth Talbot of Internal Medicine and Dr. Joseph McCune. For the Neurology Clinic, the information was provided by Mary Davidson of Radiology, Maureen Howell of Neurology, and Dr. Linda Seiwa. Once the steps were identified, surveys were used to determine how long the main steps of the process were taking to complete. These surveys were stapled (by Mary Davidson) to all the reports Radiology printed for these two clinics for a period of 7 working days (November 9-1 7). There were 23 Arthritis and 31 Neurology surveys returned which were statistically analyzed. The process for both clinics was flowcharted. See Flowcharts 2 and 3, pages Results All outpatient reports were printed in the evening and were put in the physician s mailbox (located,in the clinic) the following day. Delays occurred from the time the report was put in the physician s mailbox to when it was taken out and read. These delays are explained by the fact that physicians in these clinics do not work in clinic every day (some only work one day a week) and they only get their mail on the days they are in the clinic. In general, physicians read the reports immediately after taking them from their mailbox. Sometimes secretaries got the mail and left it on the physician s desk. In this case, the physician would read it the next time he/she was in clinic. The overall process from printing to review took longer in the Arthritis clinic than in Neurology. See Figure 3, page 21. Arthritis averaged almost 2 days, whereas Neurology averaged 4 days. This may 14

21 Room on third floor Taubman and did not arrive in the Arthritis clinic until about 3:3 pm each day. In contrast, Neurology reports are sent 15 This accounts for almost a full day of the time difference. Also, the directly to the clinic and are waiting when the clinic opens at 8: am. be because reports for Arthritis were sent via the Ambulatory Records Neurology clinic is open 8 am - The processes for both outpatient clinics were similar. There when they were reviewed by the ordering physicians. However, there into as a way of report distribution. difference. were no extreme delays from the. time the reports were printed until was some delay which was dependent on the physicians work should be sent directly to the clinic instead of via the Ambulatory Records Room. Also, automatic facsimile transmission could be looked review, Arthritis reports (and all other similar outpatient clinics) In order to shorten the time span from printing to physician Recommendations Conclusions schedules. only work in the afternoons which may explain the rest of the time pm weekdays and Arthritis physicians 5 Outpatient Clinics

22 Physician Copy of Flowchart 2 Physician Copy (Internal Medicine) Rheumatology/Arthritis 16 ort for a (bulk) in tube from Radiology to Reports are sent 1pm Reports are Outpatient Clinics Day 11 p m Day Day 1 Records Room no Put report in Day 1 3rd floor Clinic Records Room Before noon Ambulatory mailbox in Report is put in yes 3rd floor outgoing mail Day 1 aubman Clinic? 6:3am by Ambulatory Report is received ( Records Room (3rd floor Taubman) Ambulatory printed

23 Outpatient Clinics -.3:3O pm flv 1 Person from Internal Medicine goes to Ambulatory Records Room to pick up mail and brings it back to Internal Medicine rtfornis report for a internal 3rd floor Report is put in outgoing mail yes yes Day 2 3:45pm Day 1 Report is put in physician T mailbox Physician or secretary gets mail from box ) 1 [Report is returned to Ambulatory Records Room +/- 1.3 days Day] 2 /- 2.1 days Physician reads report 17

24 Outpatient Clinics C 18

25 Outpatient Clinics Neurology Physician Copy Physician Copy of Reports are 1 pm Day printed Flowchart 3 Reports are sent (bulk) in tube from Radiology to 1 1 pm Day Neurology Clinic in Taubman 8 am Day 1 Report is received by Neurology Is report for Neurology? --- back Report is sent to Radiology in tube yes Day 1 1 am Day 1 Report is put in Physician s mailbox 19

26 mail from box Outpatient Clinics discarded Report is report until it is taken care of Physician keeps report Physician reads secretary gets Physician of 2 system Report is filed from bin Clerk gets report in shadow report in bin Physician puts iys.98 a

27 ARTHRITIS NEUROLOGY oi.. Figure 3 OUTPATIENT CLINICS Working Days a) -D E r Jz cd ) a) > (I) >% o ) C a N=23 sd=3.3 I N=23 sd=1.4. : N=3 1 sd9 N=23 sd=3.7 Procedure Prinhing to Procedure to Prinhing Review to Review -H Process

28 Outpatient Clinics Procedure to Printing Times Methodology Reports printed for each of the two outpatient clinics were collected for a period of 7 working days (November 9-17). The date of the procedure was given on each printed report. The number of working days for each report was counted. There were 39 Arthritis and 59 Neurology reports studied. Results From procedure to printing, Arthritis and Neurology reports took an average of almost 6 and 4 working days with standard deviations of 3.4 and 2.7 working days, respectively. Combining both outpatient clinics gives an overall average of 4.7 working days with a standard deviation of 3.1 working days. See Figure 4, page 23. This process seems to be quite variable. One report was printed the same day of the exam while another took over 3 weeks to be printed. As shown above, Arthritis reports were taking longer than Neurology reports. When looking at Arthritis and Neurology reports separately, significant correlations between number of days and type of procedure did not exist for either clinic. In the Arthritis clinic, there seemed to be a high correlation between the number of days and the radiologist who read the films. Of the 39 Arthritis reports, 25 took 5 or more working days from procedure to printing. Of these 25 reports, 22 (88%) were signed by the same Radiologist (Dr. Joseph G. Craig). On some he signed as the Radiology House Officer and others he signed as the Attending Radiologist. Furthermore, of the Arthritis reports studied, there were only 2 that Dr. Joseph G. Craig had signed that were printed in less than 5 working days from the procedure. In the Neurology clinic, no significant correlation existed between Radiologist and number of working days. The average number of working days from procedure to printing was recalculated for the Arthritis clinic excluding the ones signed by Dr. Joseph G. Craig. The new average was about 4 working days with a standard deviation of 4.2 working days. (the previous average was 6 22

29 U) C, U) -S Figure 4 OUTPATIENT CLINICS Procedure until Printing Reports (- 3 w E z ) C Ave 1=4.7 s.d.=3 co L() (N O O COO N r co O (N (N (N ) LQ U) N- N- CO Reports

30 Outpatient Clinics working days). As you can see, the average time decreased by 2 working days and the variation slightly increased. Conclusions The Arthritis reports are taking longer on average than the Neurology reports from procedure to printing. However, excluding Arthritis reports signed by Radiologist Dr. Joseph G. Craig, both clinics took around 4 working days. Recommendations The Radiology process from procedure to printing should be studied in greater detail. The areas where there are time delays should be identified and improved. One area to pay special attention to is the delay from transcription to signing by Radiologist, It may be helpful to keep track of the number of days from transcription to signing for each Radiologist and compare them. ( 24

31 The methods available for obtaining Radiology results were 4. Log on to Pathnet 25 next most frequently used (approximately 1 4% each). A method several defined by the Radiology Department. Additional Findings exams they order. Two things trigger their memory: receiving a hard copy or a patient s return visit. It is important that the physician receives the hard copy before a patient returns, especially if reading the hard copy referred to only the reports that had not been reviewed by another method previous to receiving the hard copy. Seven physicians from the Neurology clinic were surveyed including 1 1 physicians added that they used was viewing the films personally. immediate treatment is required. In fact, if a patient is not scheduled for a follow-up visit and the physician does not receive a report, the The outpatient physicians do not keep a record of the Radiology it is obvious that the hard copy was, by far, the most frequently used Faculty physicians from the Arthritis clinic were surveyed. Twenty Faculty, 2 Fellows, and 7 House Officers. The results were similar in both clinics. From Figure 5, page 26, A survey was used to determine the percent of the time each 6. Radiologist calls ordering physician 2. Call Radiology Department 3. Log on to RIS 5. Read hard copy Methodology method was used in the Arthritis and Neurology clinics. In this survey, Results method (over 55% of the time). Logging on to RIS and Pathnet were the Methods used by Physicians to Obtain Radiology Results Outpatient Clinics 1. Listen to RTAS digital dictation

32 :.fl n CD D C) (j Figure 5 OUTPATIENT CLINICS Methods Used by Physicians to Obtain Radiology Results NJ -c 4-4- C C) td V (1) Cl) 1) I Arthritis Neurology lard Copy RTAS RIS Pathnet Radiologist Called Viewed Called Radiologist Method Films

33 Outpatient Clinics patient will not receive any treatment. This can have dangerous consequences. For these reasons, outpatient physician s rely on receiving the hard copy of the report in a timely manner. A number of the physicians surveyed provided comments regarding Radiology results. On specific methods: A lot of people do not know about RTAS It is easier to get results now that they are on Pathnet RIS and Pathnet are very cumbersome to use--too many steps are required to log on The menus on RIS are nice but I can t remember how to log on or my doctor number I don t have time to play around on the computer (RIS and Pathnet) RIS is irritating to sign on to -- too many steps required It takes too long to sign on to RIS and there are not enough ports Tactics to get Radiology results on Pathnet are unknown In 5 years I have received only 1 call from a radiologist Radiologists should call when there are important findings On timeliness: MRI hard copy reports are very slow in coming -- sometimes weeks Non CT/MRI reports take forever to get hard copy (e.g. routine CXR) It still takes several hours for wet readings (want results right away) Approximately 3% of the time a patient comes for a return visit, the report is not in their chart Many times per week there is no hard copy in the chart upon a patient s return visit 27

34 I only work in the clinic one day a week -- If a patient comes for a return visit and I did not receive a sent to my office in Kresge so I would get them sooner reports should be visit It is embarrassing not to have a patient s results upon a return 28 and there was no hard copy in the patient s medical record. were used primarily because the physician had not received a hard copy Conclusions most frequently used method by the outpatient clinics. Other methods Reading the hard copy of the Radiology report proved to be the reports should be standard name of the patient listed before the last name -- all The system is overall pretty good File room service has improved dramatically in over the past Radiology reports are the only ones printed with the first Miscellaneous: go talk to a Radiologist, he/she often gives a different. signifies poor quality and inconsistency interpretation than in the initial report I received -- A number of times I have found reports for the wrong patient If there are interesting or difficult reports to interpret and I outpatient reports should be on the chart in 2-3 days results are not on the computer meaning the films have Films should be read within 24 hours -- copy of the report should be in the physician s mailbox -- computer (Pathnet) -- not yet been read inpatient reports should be on the chart in 1-2 days -- hard copy of the report, I look for the results on the Outpatient Clinics a couple of times a month the the On quality of service: in a medical record--one record had 1 7 misfiled reports this 2 years following day a C

35 Outpatient Clinics Recommendations Since the hard copy of the report is the most critical of the methods available to obtain Radiology results, much effort should be concentrated on reducing the time it takes to receive them. A complaint that was expressed a number of times was the numerous steps required to access results on RIS and Pathnet. Developing an easier way to access these systems would likely increase the frequency they are used. It seemed that many physicians were not familiar with all of the available methods to obtain Radiology results and/or how to use them. In particular, many had not heard of the RTAS digital dictation system. Informing physicians of the different methods and instruction on how to access them would increase the frequency they are used. Finally, if all other hospital reports do in fact list the patient s last name before the first name, it is suggested that Radiology reports do the same (to make it less confusing). 29

36 Satellite Clinics Satellite Clinics Flowcharting: Post-Printing Process Methodology The satellite clinics that were studied included Briarwood Family Practice and the University of Michigan Medical Group - Briarwood Campus. In order to determine the routing. procedure for the hard copy reports to these clinics, interviews were conducted to identify each step in the post printing process. This information was provided by Bonnie Melton and Mary Davidson of Radiology, Sherry Rader and Sharon Redmer of the University of Michigan Health Centers, and Mary Ann Ryan of the University of Michigan Medical Group. Once the steps were identified, surveys were used to determine how long the main steps of the process were taking to complete. The surveys were attached by members of the task force (Bonnie Melton in the morning and Mary Davidson in the evening) after the reports were printed. They were attached to the hard copies for the six working days between October 29 and November 5, The surveys asked certain people to fill in the date and time in which they fulfilled their part in the process. The final step in the process was the placement of the hard copy report in the patient s medical record. At this time, the survey was retrieved. Resu Its: The steps of the report routing procedure for the satellite clinics and the times for certain sequences of events are displayed in Flowchart 4, pages The time span from the report printing until the radiographer retrieves the report from her mailbox is very stable. The report is printed at approximately 9:3 p.m. or 5:3 a.m. and the report is received by the radiographer at about 1: p.m. that day. There appears to be no variation due to the courier. The time span for the reports to be separated by the Radiographer and distributed to the correct clinic is also fairly stable It takes the Radiologist approximately 27 3

37 31 Printed reports Records Room Instructions 9:3 p.m. or 5:3 a.m.. Entered into Reports separated Reports Printed in morning Computer removed from printer in copies (grey) drawer placed on under desk envelopes interdepartmental Clinic labels in s.d. = 8 mm Reports Printed previous evening s.d. = mm separated by clinic 4r N = 21 (pink) and Doctor Records copies t = 2.3 hours t=1.5hours [ports Printed - Printing Flowchart 4 into Medical Both copies Briarwood Campus Practice and University of Michigan Medical Group - N=38 Report Routing Procedure for. Briarwood Family Sateflite Clinics

38 Satellite Clinics Both copies placed inthe corresponding clinic envelope I I All envelopes placed in out bin next to desk r 8: am. Courier picks up mail from out bin Courier delivers mail to front mailbox of Briarwood Family Practice Briarwood Family Practice Clerical Staff sorts mail 3j

39 33(y) Hardcopy Radiographer sorts book that final through reports to order by date patient put in placed in Reports for each together ---- mailbox s.d. = 28 mm t = 5.4 hours Satellite Clinics N ol checks off log been returned reports have Radiog ra phe r the same patient put all reports on up mail 1: p.m. Radiographer picks Radiographers Radiology Reports

40 Satellite Clinics (2) Radiog rapher reviews each report yes hingno abnormal? P Radiographer places report in pile to be sorted that physician present? no Radiographer pulls patient chart yes VI Radiographer personally hands report to physician Radiographer gives chart to another physician or nurse on duty U 34

41 it report into port and initials mailbox Physician reviews physician s to UM Medical adiographer gives reports to receptionist at front desk Group LIks over reports Briarwood 35 s.d. = 16 mm t = 27.2 mm N=46 Medical Group) (Briarwood Family into clinics Reports sorted Practice or UM Radiographer C) N=17 s.d. = 11. mm t=26.1 mm Family Practice Satellite Clinics

42 t = () Satellite Clinics t=1o.9min 1 be,/ s.d.=lomin \N=13 Clerical staff Physician places \ sorts reports by report in box to physician filed 5.4 hours s.d. = 9.3 hrs N=44 Reports pced in mailbox yes Clerical staff attaches report to patient medical record t = 8.4 hrs s.d.=8.9 hr Physician reviews report and initials it Physician places report in basket at end of hall Clerical staff removes reports from basket 1 36

43 Satellite Clinics Reports placed in a basket in the medical record area Clerical staff sorts loose filing by terminal digit number t= 11.5 hours s.d. = 4.5 hrs N=3 Ii no 4 Clerical staff attaches report in patient medical record 37

44 Satellite Clinics they a minutes to complete her duties and distribute the reports in the physicians mailboxes at Briarwood Family Practice and another 26 minutes to walk the appropriate reports over to the University of Michigan Medical Group clinic. Once the reports were distributed in the physicians mailboxes, many opportunities for time delays arose. The average amount of time for the a physician at Briarwood Family Practice to review a report and initialize it was 7.7 hours with a standard deviation of 1.4 hours. This variation was due to the fact that many of the physicians were not in the clinic the day the report was received. Many doctors noted if were out of the clinic on the day the report was received by the Radiographer If the physician was in that day, it was usually reviewed that same day or the next morning If they were not in that day, it was reviewed on the day they returned The average time for a report to be filed at Briarwood Family Practice was 5.4 hours with a standard deviation of 9.3 hours. Once again, the reports were usually filed the same day it was initialized by the physician or early the next morning. For the University of Michigan Medical Group, the average time for physician to review a report and initialize it after it is placed in her mailbox is 8.4 hours with a standard deviation of 8.9 hours. Similar to Briarwood Family Practice, the report was usually reviewed the same day it was received or early the next morning. The filing time at this clinic was greater than at Briarwood Family Practice, taking an average of 11.5 hours with a standard deviation of 4.5 hours. Additional Findings: Of the 75 reports that were tracked for both clinics, 9 reports (1 2%) were unable to be located up to three weeks after the report was printed. Where these reports ended up is of great concern. Of the 9 reports that were missing, 6 were for patients at the U of M Medical Group and 2 were for patients at Briarwood Family Practice. One report was for a patient that neither clinic claimed to have seen. Whether or not the reports ever returned to the clinic is unknown. Because of the backup in the loose filing at the U of M Medical Group, it is possible that some reports were waiting to be filed. 38

45 Satellite Clinics Conclusions; The time periods for each sequence of steps in the process are fairly consistent and reasonable. The most variation in the procedure occurs in the physician review time and the filing time. Since physicians do not always work in the same clinic every day, they are often unable to review the reports immediately or even that day. The physicians appeared to review the reports as soon as they were available to do so. The filing procedure was also carried out as soon as the clerical staff was available to do so. The filing procedure at Briarwood Family Practice appeared to be much more efficient than that at U of M Medical Group. In fact, only three surveys from U of M Medical Group filled in the time that it took for the clerical staff to file the report. Upon observing the filing procedure at the U of M Medical Group, it was noted that there were many piles of loose filing and the clerical staff was very behind in their duties. Recommendations: Since there are no extreme time delays in the process of printing to the posting of the report, the Radiology process from procedure to printing should be studied in greater detail. 39

46 Satellite Clinics Procedure to Printing and Overall Turnaround Times Methodology Reports printed for Briarwood Family Practice and the University of Michigan Medical Group were collected for the six working days between October 29 and November 5, The date of the procedure was given on each printed report. The number of working days that existed from the day the procedure was completed until the day the report was printed was determined. 57 reports were studied for this part of the process. In addition, the number of working days that existed from the day the prodedure was completed until the day the report was attached to the medical record was also calculated (overall turnaround, time). 46 reports were studied for the overall turnaround time. Results As can be seen in Figure 6, page 41, the average number of ( working days from a procedure to the printing of the report is 3 4 working days with a standard deviation of 2.5 working days. This process seems quite variable. One report was printed the same day of the exam while another took 12. working days to be printed. Figure 6 also shows the average number of working days from the procedure until the report was attached to the medical record (overall turnaround time). The average number of working days from procedure until posting is 5.9 working days with a standard deviation of 3.6 working days. Conclusions The overall time delay from procedure to printing of the reports was significant and variable. Recommendations The Radiology process from procedure to printing should be investigated further to identify specific delays and their causes. C 4

47 . i.: I In. Figure 6 Average Number of Working Days for Reports to be Processed - c) -Q z I) V > 1-I, > D) I N=57 s.d.=2.5 II i ij ik. L 1iiy N=46 sd.=3.6 Procedure until Procedure until printed posted in chart Process r

48 Satellite Clinics Date of Procedure or Date Films Received by Clinic Sent In to Date In the past, there have been many complaints from the satellite clinics that hard copy radiology reports have not been returning in a timely manner. To investigate this concern, the radiology reports have been separated into two types: reports from exams taken at the hospital and reports from exams taken at the satellite clinic. Reports from Exams Taken at the Hospital Methodology To determine the average amount of time for reports to return to satellite clinics after an exam is taken at the hospital, data was collected for the number of working days that existed from the day the exam was completed until the day the report was received. This data was obtained for the Northeast and Northville satellite clinics and was collected for ultrasound, gastrointestinal intravenous (Gil 1VP), and computed tomography (CT) radiology exams. Data was also collected for the percentage of reports that never returned to the clinic. The reports that never returned to the clinic were classified as missing. Missing reports included those that had not been attached to the medical record by the time the data was collected in late November. Since the data was obtained for the six months of April through September 1 992, the exam of a missing report had been done between 2 and 8 months prior. To determine the number of days for the clinic to receive the report and also thepercentage of reports missing, the medical record was pulled for every patient that had one of the three aforementioned types of exams taken over the six month period. If the hard copy radiology report was in the chart, the day the report was received was noted. If the hard copy radiology report was not in the patients chart, the report was classified as missing. / 42

49 Satellite Clinics Results: The results of the study clearly demonstrate that the average times for radiology reports to return to the Northeast and Northville clinics are very high. As can be seen in Figure 7, page 44, the average number of working days for reports to return to the Northeast clinic was 14.7 days with a standard deviation of 26.2 days, and the average number of working days for reports to return to the Northville clinic was 11.1 days with a standard deviation of 1.9 days. The reports that are sent to the Northville clinic not only get there faster, but with much less variation in time. The average number of days for the exams to return were also calculated for each of the three different exam types that were studied. Figure 8, page 45, shows that ultrasound reports took the longest to return to the Northeast clinic with an average of working days. In contrast, the CT reports took the longest, on the average, to return to the Northville clinic with a mean of 1 35 working days. It is interesting to note that the number of days for each exam type at Northville. were similar but at Northeast varied quite a bit. Since ultrasound exams were the most frequent type of exam ordered for both clinics, had a high average number of days to return to the clinics, and had much variation in time to return to the clinics, they were researched further to examine for any possible trends. Figure 9, page 46, displays the average number of working days for ultrasound reports to return to the clinics. The pregnancy complete ultrasound reports proved.to be the most signifiëant for bàthclinics. The average number of days for pregnancy complete ultrasound reports to return to the Northeast clinic was 2.3 working days and to return to the Northville clinic was working days. Since the pregnancy complete ultrasound reports for the Northeast clinic had the highest average number of days to return, the highest volume, and the highest variation in time to return, this category was examined further. The number of working days for each of the 62 samples for this category is displayed in Figure 1, page 47. This graph shows that the number of working days for pregnancy complete ultrasound reports to return to the Northeast clinic is unbelievably high in some instances. For example, sample reports

50 Figure 7 Average Number of Working Days for Reports to Return to Clinics C 4- G) -Q E z ci ci) > U, > ct N=115 s.d=26.2 N84 Northeast Northville s.d.=1.9 (1 (D (D :3 U, Clinic

51 I I 1 Northeast Northville (p (P D (1) Figure 8 Average Number of WorkEng Days for Reports to Return to CIincs - (fl ci) -Q ED z ci) c3) ci > C,) > N=99 s.d.=27.9 N=4 s.d.=9.4 N=1O s.d.=2.4 Ultrasound Gi/lVP CT Type of Exam

52 Northeast Northvi(le (F) CD CD C, Figure 9 Average Number of Working Days for Ultrasound Reports to Return 25 I. 2 N= 52 s.d.=32.o N=3 s.d.=14.o cy 4- U) >.15 s.d.=1 3.1 N=19 s.d.=12.8 -Q ED z 1 5 N=6 s.d.=9.8 2 s.d.=6.8 N=6 N=8 > Pregnancy Breast Complete Ultrasound Ultrasound Pelvis Ultrasound Abdomen Ultrasound Misc. Ultrasound Type of Ultrasound Exam

53 :_.. Lt) LO ad Lfl J. C, 4-t CD CD C, (j, Figure 1O Number of Working Days for Pregnancy Complete Ultrasound Reports to Return to the Northeast Clinic C) QC3 8 ci) 6 4 z 2 Co ( LC) Sample Number

54 radiologists for each of these ten exams were determined. Table 2 shows the radiologists who signed the reports and their frequency. (2.3 days) for the pregnancy complete ultrasound reports. The period of about seven months! and 1 7 took over 1 4 working days to return to the Northeast clinic - Ten samples largely exceeded the average number of working days a 48 tabulated with regard to the ordering physician. Figure 1 2, page 5, complete ultrasound reports to return to the Northeast clinic were reports to return (27.5 working days), conclusions are Umited by the reports (ordering 43 out of the 62 reports or 69%). She also had a very the high standard deviations for both Bord and Nicholson which indicate percentage of missing reports was tabulated. After the average number of working days for the reports to return to the Northeast and Northville clinics were determined, the much variability in the process. In addition, the average number of working days for pregnancy these ten Iuntimely!J reports. Figure 11, page 49, shows the number of working days excluding small sample size. Nicholson had the significantly highest volume of high average number of days to return with 21.4 working days. Notice displays this information. Although Bord had the highest average number of days for the 2 CV Joel Platt V Doug Ellenger 1 Richard Bowerman 3 Ron Adler V 4 Radiologist Number of Reports Table 2. Radiologists who signed the Untimely Pregnancy Complete Ultrasound Reports Satellite Clinics

55 Cl, CD c-i. CD CD C-) cj, (N Figure 11 Number of Working Days for Pregnancy Complete Ultrasound Reports to Return (Eliminating Untimely Reports) cr > C, D ) I ci) ED z 5 r- o co co c LO co I- t- r C J C\J - Sample Number CO ( CJ

56 (I, CD CD C) :3 (.3 : Figure 12 Average Number of Working Days for Pregnancy Complete Ultrasound Reports to Return to Northeast Clinic by Ordering Physician C) 3 N=6 s.d.= o -Q E z a) C) a) > U) > Cu N=43 s.d.=34.o Nicholson N=2 N=5 s.d.=3.5. s.d.=5.4 N=3 s.d.=1.5 Bord Himebaugh Rachwal Connor Ordering Physician

57 reports. Figure 1 5, page 54, displays the percentage of missing Northeast clinic, and the percentage of missing reports was 14.1%. reports. attached to the medical record. The Northville clinic had a lower percentage of missing reports with 7.7% missing. the percentage of missing reports for the three different categories of percentage of missing reports with 3 3.3% each. The largest sample Due to the large volume of ultrasound reports for both clinics, 1 6.8% of the reports from exams done 2 to 8 months prior were not missing reports with 1 6.8% of the reports missing. This signifies that The overall percentage of missing reports was broken down into for the two clinics. The Northeast clinic had a high percentage of exams. Figure 1 4, page 53, shows the percentage of missing reports for ultrasound, Gl/IVP, and CT exams for the two clinics. this category was separated into the various types of ultrasound ultrasound reports to the two clinics. The breast ultrasound and abdomen ultrasound reports for the Northeast clinic had the highest size fell in the pregnancy complete ultrasound category for the Interestingly, the pregnancy complete ultrasound reports for the of ultrasound report appeared to be the root cause of the missing Figure 1 3, page 52, presents the percentage of missing reports overall Northville clinic had no reports out of 21 missing. Overall, no one type Satellite Clinics 51

58 Percentage of Mssing* Reports Overall U, w CD i-f CD C, (n Figure 13 a) 4J ci) C-) a) N=137 Northeast Clinic N=9 1 Northville Clinic Clinic * Missing signifies that the exam was done 2 to 8 months prior and the report was not yet attached to the m-cai record

59 Northeast Northville C, I-f CD I-f CD n D C.) C ) I. Figure 14 Percentage of Missing Reports 3 25 N=15 a) ) ( 3 4J ci U a) N=117 N=76 N=5 5 N=5 N=1O Ultrasound Gi/lVP CT Type of Exam

60 ItI Northeast Northville C,, U) CD t-. CD (1) Figure 15 Percentage of Missing Ultrasound Reports to Clinics 35 N=9 - C ) ci) C-, N=71 N=8 N=4 1 5 Pregnancy Complete Ultrasound Breast Ultrasound Pelvis Ultrasound Abdomen U It rasou nd Misc. Ultrasound n Type of Ultrasound Exam

61 n n

62 Satellite Clinics Reports from exams taken at satellite clinics In the previous section, the average number of working days were determined for the reports to return to the Northeast and Northville clinics after an exam was taken at the hospital. The percentage of missing reports were also calculated for these clinics. The following sections describe the methodology and results from the study of the reports from exams that were taken at the clinic. Methodology: To determine if there indeed was a problem in the report routing procedure to the satellite clinics for exams that were taken at the clinic, data was collected for the number of working days that existed from the day the film was sent in until the day the report was received by the clinic. The five clinics studied were Briarwood Family Practice, the Northeast clinic, the Northville clinic, the Brighton clinic, and the Plymouth clinic. The data was obtained from logs that were kept by the clinics and were for the four months of February, May, August, and October All exams taken at the clinics during these time periods were investigated. Results: The average number of working days for a report to return to each clinic after the film has been sent in can be seen in Figure 1 6, page 56. The overall average return days for the clinics was 7.1 working days with a standard deviation of 4.6 days. There was a 2 working day difference between the various clinics. After the average number of working days were determined for reports to return after an exam was taken at the clinics, these averages were compared to the average number of days for reports to return from exams taken at the hospital. Figure 1 7, page 57, shows the comparison of the average number of working days for reports to return to the Northeast and Northville clinics. The average number of working days are shown for the reports from exams done at the hospital and from the exams done at the clinic. For both clinics, the average number C C 55

63 CD CD D In Figure 16 Average Number of Working Days for Reports to Return After Films are Sent In ) 4- -Q ED z > U) > Briarwood Family Practice N= 177 s.d.=4.2 N=17 s.d.=4.7 Northeast Northville Clinic Clinic Brighton Clinic Plymouth Clinic Clinic

64 CI) CD CD C, (n I. a) -Q E z a) ) Ct a) > C,) > Ct ) C L. Figure Q N=115 Average Reports s.d=262 Number of Working Days for to Return to Northeast and Northville Clinics N=177 s.d.=4.2 N=84 s.d.=1 1 Northeast: Northeast: Northville: N=17 s.d.=4.7 exam exam exam exam done at done at done at done at hosp clinic Clinic Northville: hosp clinic

65 wrong clinic. In fact, 41 reports investigated were sent to doctors at The variation in time was also much greater for the reports from medical records, it was noted that every one that was found was filled 58 exams done at the hospital and 8. days for those done at the clinic. exams taken at the hospital. The standard deviation for the Northeast days. Similarly, the standard deviation for the Northville clinic (exam deviation for the exam done at the clinic was 4.7 working days. clinic (exam taken at hospital) was 26.2 working days, whereas the average number of working days was days for the exams done at taken at hospital) was 11. working days, whereas the standard Additional findings: investigation arose. First of all, while studying the Northeast and While determining the average number of working days for the those exams taken at the hospital. For the Northeast clinic, the the hospital and 7.6 days for the exams done at the clinic. For the standard deviation for the exam done at the clinic was 4.2 working reports to return to the clinics, other opportunities forfurther reports to return after an exam is completed at the hospital, it was the Northeast clinic who did not work there. This is equal to 1 8% of all the exams studied. Furthermore, these 41 reports included 1 2 doctors. Northeast clinic. One doctor to whom a report was sent was not in the satellite system at all. In addition, reports were sent to the wrong caused by wrong location information on the report. out correctly and could be easily read. Upon looking up most of the illegible referrals in the patients physician name or code written on the referral form was unreadable. exams labeled as having illegible referrals. This indicates that the In addition, the hospital records that were reviewed had some doctor at the correct clinic, and reports were sent to clinics for patients that did not belong to that clinic. Most of these errors were Many of those doctors worked at the Northville clinic instead of the found that many of the reports were sent to the wrong doctor or to the of working days for the reports to return was significantly greater for Northville clinic, the average number of working days was 11.1 for the Northville clinics to determine the average number of working days for Satellite Clinics

66 of working days for reports to return after an exam is completed at the primary suggested target area. Although the pregnancy complete 59 the most urgent area of concern since they are the most frequent type the report, no significant findings were present. Doctor Nicholson at the Northeast clinic is the main ordering physician of concern due to clinic. These reports also have a significantly greater variation in hospital is much greater than those reports from exams taken at the clinics after an exam is taken is extremely high. The average number The average number of working days for reports to return to Conclusions and Recommendations: time to return. The ultrasound exams taken at the hospital appear to be ultrasound reports for the Northeast clinic were further investigated for trends in the ordering physician and the radiologist responsible for of exam and have a high average number of days to return and a high variation in time. The pregnancy complete ultrasound reports are the size. Satellite Clinics several of the reports are being returned to the wrong clinic or the scheduled. This is also difficult due to the large volume of referrals. for those exams that are taken at the clinics and the films are sent in, wrong physician. Although excellent records are kept by the clinics exam taken as requested, or they change the day that the exam was hospital. This is a difficult task since many patients do not get the no records (or very few) are kept for those exams that are taken at the returning, many of them are taking several weeks, or months! Also, reports is very disturbing. Furthermore, of the reports that are be the most significant. Since the hard copy is the stimulus for many physicians to take action on a patient, the high percentages of missing than the Northville clinic and none of the three exam types appeared to The Northeast clinic had a higher percentage of missing reports the number of days it took, however, this analysis had a limited sample her large volume of reports, large average number of days for the return. The radiologist who signed the report was not correlated to reports to return, and the large variation in time for her reports to (

67 C month so they can monitor the process. Investigating the procedure once the patient leaves the clinic investigation include: The difference between films that are taken at the clinics. This referral form should be completely filled out by the on the referral. Standardizing referral forms would insure that all clinics are providing the same information in the same area of the the physician works at more than one clinic, this fact should be noted of referral forms used by the various clinics. To help eliminate the physician identification code, the ordering clinic, and its address. If major problem and steps need to be taken to eliminate it. delays, one standardized referral form should be developed for all ordering physician and include the ordering physician s full name, hospital and films that are taken at the clinic 6 Are the patients bringing their forms to radiology? all of the reports being sent out? much longer to read and return the report? Why are the films taken at the hospital taking entered in the computer accurately? department? How long does it take at each step in the radiology - Are Is the information verified by the patient? If not, where is the information acquired from? If so, are they properly filled out? Is all of the pertinent information correct and being the ordering clinic and the date that the report is received by the clinic form. This would make it easier for receptionists who enter this data into the computer. In addition, one copy of the form should be kept by should be noted. This information should be sent to radiology once a with the referral form is also recommended., Areas of suggested The hospital registration procedure The tracking system in the radiology department What is causing the time lapse prior to printing in the However, the untimeliness and large number of missing reports are a First of all, at the present time, there are many different types radiology department? Satellite Clinics

68 which forms are generating reports that are taking more time to return. that was being used. This information could be helpful in determining If it is impossible for one standardized form to be used for all clinics, a study could be initiated that tracked every different form Satellite Clinics allowing the satellite clinics to enter the necessary information A number of reports are being sent to the wrong location. 61 to the report may be helpful in eliminating any confusion when sorting Currently, when a clinic receives a report they did not request, a staff directly into the hospital computer system. for the report. If the correct destination is identified, the report is Another alternative is to eliminate hard copy referral forms by Other suggestions include using automated facsimile by updated in the computer each time she is reassigned. This would avoid confusion. problem is the location codes. During the study it was found that some of the clinics had numerous codes and there were always new ones being added. Each location should have one and only one code! All of the location codes for the satellite clinics should be reviewed and at the clinic, sent back to radiology, or thrown away. The root of this the batches after they are printed. the same name, adding the physician s code to each document would The clinics in which each physician practices should be hopefully eliminate the many. reports being sent to a doctor at an member often searches in the computer to locate the proper location forwarded. If the patient is unidentifiable, the reports are either kept duplicate ones eliminated. Moreover, adding the full name of the clinic thoroughly reviewed for accuracy. The physician s new locations should incorrect location. ALso, since there exists several physicians with transmission as a way of report distribution or having satellite clinics report distribution time. print out their own reports. Either of these would greatly decrease - ( (

69 radiology report before it is placed in the patient s medical record. Eighteen physicians responded to the survey and the results are Q The five categories listed on the surveys were 62 other way prior to the arrival of the hard copy. This clarification was necessary since every physician must review and initial the hard copy Copy as a choice only if they did not discover radiology results in any Briarwood Family Practice, the Northeast clinic, and the clinics in Brighton, and Plymouth. The surveys asked the physicians to obtain radiology results, a survey was sent to several physicians at indicate approximately how often they used each of five methods per week in percentages. The physicians were instructed to mark the Hard In order to ascertain the various methods used by physicians to Methodology comments. Results the hard copy radiology report is the most frequently used method by the physicians at the various clinics. The physicians claimed to use Pathnet was the second most frequently used method, being used displayed in Figure 1 8, page 63. The results clearly demonstrate that this method approximately 4.5% of the time per week. Accessing An other category was also present, along with space for additional 4. Access Pathnet 3. Access the Radiology Information System (RIS) 5. Read the Hard Copy Report 2 Call the Radiology Department Directly Use the Digital Dictation System (RTAS) Methods Used by Physicians to Obtain Radiology Results Sateflite Clinics Northville, 1.

70 Methods Used by Physicians to Obtain Radiology fl - C,, CD CD C-, Satellite Clinics Figure 18 Radiology Results 45 cl) U) ci) E II i Ii I 4-, a) C-) ci) I 1Ii.i i.ii I I : Hard Copy PathNet RIS RTAS Call Method

71 approximately 21 % of the time. Furthermore, the Radiology Information for obtaining radiology results and that was to ask Mary Neely. called directly 5.5% of the time. Only one other method was mentioned (RTAS) was used 1 4% of the time, and the Department of Radiology was System was accessed 1 9% of the time, the Digital Dictation System 64 Conclusions by Clinic) Satellite Clinics method by physicians to obtain radiology results and is also the most preferred method, steps should be taken to reduce the number of (less) variation. if they are returning at all, and if they are returning with improved be initiated to monitor if the reports are returning in a timely manner, Since the hard copy radiology report is the most frequently used working days for the reports to return. Tracking systems should also Recommendations helpful in cauing in the past. ( time. They stated they could not use the hard copy as their only source In addition, several physicians that use methods other than the the results for a patient until the hard copy is received. This point is to the clinics. (See section entitled Date of Procedure to Date Received radiology results. This indicates that many physicians do not act on hard copy claimed they would prefer to use the hard copy 1% of the of obtaining results since they often took several weeks to return. used method by physicians at the various satellite clinics to obtain procedure as well as the large percentage of reports that never return turnaround time. Furthermore, one physician emphasized the importance of the radiology department contacting the physician if a very disturbing due to the large delays in the radiology report routing Ultrasound reports were often mentioned as having the longest problem was discovered. He indicated that the department has been The hard copy radiology report proved to be the most frequently

72 Outside Referring Physicians Outside Referring Physicians Flowcharting: Post-Printing Process Methodology In order to determine the routing procedure for outside referring physician reports, interviews were conducted to identify each step of the post printing process. For the Michigan Headpain and Neurological Institute (MHND, this information was given by Mary Davidson of Radiology, Barbara Pore of Radiology, and Marjorie Winters of MHNI. Once the steps were identified, the process was flowcharted. See Flowchart 5, pages Marjorie Winters provided a list of the exams MHNI had ordered over a 3 month period (August-October). Included was the type of exam, date of procedure, and date received by MHNI. The number of working days each exam took was counted. There were 9 exams ordered during this period (7 MR1, 2 CT). - : Results Radiology reports took on average 8.4 working days with a standard deviation of 2.6 working days from the date of procedure until the date they were received by MHNI. See Figure 1 9, page 69. Barbara Pore was the person responsible for sending out the outside referring physician reports. According to her, the main cause for delay is due to the mailing location printed on the reports. The correct address is supposed to be printed on the report. When this is not the case, Barbara spends time searching in the computer to find out exactly who the ordering physician was and to see if the address was entered after the report was printed. If not, she searches her other resources to find an address for the ordering physician. If she is unsuccessful, she sends the report to the department the films were generated from with a letter. The letter explains that she is unable to find an address for the physician and if they have one to please forward the report and inform her of the address for future reports. If they do not have an address, they are instructed to return the report to Barbara. C 65

73 Outside Referring Physicians Michigan Headpain and Neurological Institute Physician Copy of Reports are printed 4-1O pm DayO Physician Copy Flowchart 5 Report is put in Barbara Pore s mailbox Midnight Shift Day 4 Barbara Pore removes report from mailbox 4 Morning Day 1 Report is sent to the department the films were generated from with a letter stating that she is unable to find an address for the Doctor Report is put Ifl envelope Address is written on report 66

74 B2 mail room on level Report is taken to r C Outside Referring Physicians the Physician Assistant Report is read by report in U.S. mail MHNI receives by U.S. mail report is sent out Mail is sorted and (f) 67 Department Radiology Call to inform Afternoon n no :evt C

75 Outside Referring Physicians Q) Are there any important findings? yes Report is put in Physician s mailbox Dayn Report is mailed back to Radiology Department Day n Report and patient chart are put in physician mailbox Physician reads and signs report and puts it in to be filed bin Day n 1 Day n 1 Physician reads report Report is filed in patient chart atmhni Patient is asked to go to Radiology Department to sign out films 4- [Physician views films and sees patient for a return visit 68

76 I :i I Figure 19* ci). E z ci) ci) > Cl) >% C) C OUTSIDE REFERRING PHYSICIANS Working Days N=9 sd=2.6 Procedure Until Received by Clinic Process - - I Michigan Headpain and Neurological Institute

77 read them that day or the following day. back a week to 1 days following the procedure. MHNI keeps track of receive the hard copy. Also, sometimes MHNI does not realize that they name and/or address) information. Therefore, it seems that the root of the above problems which, cause her to get backlogged, she admits that sometimes reports are sent only once or twice a week. indicating outside referring physician Barbara is supposed to send out reports on a daily basis. Due to really for an inside physician reports that say they are for an outside physician but are reports that do not have 1W before the physician s name doctors who have more than one doctor number Other problems Barbara faces are: Conclusions 7 physicians seems to be due to missing location (ordering physician s this problem lies in the entering of this information. The main delays in the post printing process for outside referring Again, they call for a verbal reading. would prefer being able to sign out these films directly. the exams they order. When reports are not received after two weeks, the state and this requires an extra driving trip to Ann Arbor. MHNI Another issue that Marjorie Winters brought up was that MHNI Marjorie Winters explained that MHNI wants to receive reports sent out. requests that a hard copy be sent. It still takes about a week to Outside Referring Physicians If Barbara cannot locate the ordering physician, the report cannot be Upon receiving Radiology reports, MHNI s physicians generally MHNI calls Radiology for a verbal reading of the report (flqt RTAS) and did not receive a report until the patient comes for a follow-up visit. likes to see the films for all abnormal reports. In order to get these films, the patient must go to the U of M Hospital to sign them out. This is very inconvenient for the patients. Many live out of town or out of

78 Outside Referring Physicians Recommendations People (Le. receptionists) who are entering the location information (ordering physician s name and address) into the computer need to make sure that these parts are completely and accurately filled in. Before assigning a new doctor number, they need to make sure that one has not already been assigned to the physician. They also need to verify if the physician is an inside or outside physician. Note: According to Barbara Pore of Radiology, the new UNIX number system will eliminate the O/R code which will help alleviate problems. Another recommendation is to allow outside referring physicians to sign out their patients films directly. ( 71

79 Outside Referring Physicians Procedure to Printing Times Methodology All outside referring physician reports printed over a 5 day period were analyzed to determine the number of working days between the procedure and printing of each report. The sample included 1 3 reports. The number of working days equals zero for a report that is printed the same day of the procedure. Results From procedure to printing, outside referring physician reports took an average of 3.1 working, days with a standard deviation of 4.6 working days. The number of working days ranged from to 1 8. Conclusions Results showed that 3.8% of the reports were printed in 1 working day, 61.5% were printed in 2 working days, and 92.3% were printed in 3 working days following the procedure. One report took 1 8 working days. Recommendations Identify where delays occur in the process from procedure to printing of the reports. Improve the process to minimize these delays. 72

80 Outside Referring Physicians Methods used by Physicians to Obtain Radiology Results Methodology The methods used to obtain Radiology results were explained by Marjorie Winters of the Michigan Headpain and Neurological Institute (MHNI). Results MHNI relies on receiving a hard copy of the report in their United States mail. If a report has not been received after two weeks following the date procedure, MHNI calls Radiology for a verbal reading of the report (flq.t RTAS) and requests that a hard copy be mailed. Conclusions Reading the hard copy of the Radiology report was found to be the only method used by these outside referring physicians (unless the report was not received in a timely manner). Receiving these hard copies was taking longer than MHNI desired in about half of the sample studied in the preceding section on Flo wcharting: Post-Printing Process. Recommendations Since the hard copy of the report is the critical method used by outside referring physicians, it is important that it is received in a timely manner. Ways to improveare covered in the sections Flowcharting: Post-Printing Process and Procedure to Printing Times. When MHNI did not receive a hard copy, they called Radiology for a verbal reading of the report. MHNI was unfamiliar with the RTAS digital dictation system. Outside referring physicians should be informed of this method in order to save the time and effort of Radiology personnel. 73

81 Outside Referring Physicians Another suggestion is to consider using automatic facsimile transmission as a way of report distribution. 74

82 OveraI Comparisons Number of Days from Procedure to Printing Methodology A sample of printed reports was taken for inpatient units, outpatient clinics, satellite clinics and outside referring physicians. The number of days from procedure until printing was calculated for the inpatient units and working days were calculated for the other types. Results Figure 2, page 76, shows the averages for the four types studied. Inpatient reports took an average of 3.1 days. Outside referring physician, satellite clinic, and outpatient reports took average working days of 3.1, 3.4, and 4.7, respectively. For more detail on individual studies, see the section called Procedure to Printing for the desired type of clinic. Conclusions (N Outpatient reports are taking the longest amount of time from procedure until printing of the reports. C 75

83 (D CD Di C,, D C,, AM Clinics ZY) I.-1 ** E D z -K -K Cl) Figure Total Days for Inpatient Units Comparison of Procedure until Printing Times 4.7 Inpatient Outpatient 3.4 Satellite Units Clinics Clinics Type 3.1 Outside Referring Physicians

84 Listening to RTAS and accessing RIS were both approximately 77 (RTAS) or are available on Pathnet. Surveys were used by inpatient, outpatient, and satellite clinics copy is the single most frequent method of obtaining radiology results referral physicians. Looking at the X-ray in person, however, is the to determine the percent of time each method was used by physicians to obtain radiology results. An interview was conducted for the the most important method for outpatient, satellite, and outside overall. With all four clinics combined, the hard copy is the only Figure 21, page 78, clearly demonstrates that reviewing the hard Methodology outside referring physician to gather this information. Results method of obtaining radiology results for 52% of the time. In fact, it is most important method used by inpatient physicians to obtain results. most frequently used method for the outpatient, satellite, and outside often can not wait until the results are in the digital dictation system satellite clinics. Conclusions frequently used method for the inpatient clinics. The inpatient units prefer to use this method because of the urgency of their work. They Reading the hard copy of the Radiology report proved to be the used 1 4% of the time by inpatient, outpatient, and satellite physicians. Accessing RIS and Pathnet were both most frequently used by the referring clinics. Looking at the X-ray in person was the most Methods Used by Physicians to Obtain Radiology Results Overafl Comparisons

85 (t 3 -o - cn cj. I I Figure 21 Methods Used by Physicians to Obtain. Radiology Results - co -D C,) a) E 4) C ci) C-) Hard Copy.DTTB I Inpatient Units Outpatient Clinics WI Satellite Clinics Looked at RTAS RIS Pathnet Radiology Person Outside Referring Physician Physician the X-ray in Called Called Physician Radiology Method

86 non-priority. Priority sheets must be fifed within 3 days of receipt and non-priority within 7 days. The category a loose sheet will be placed Services Department and approved by the Ambulatory Records Unit signed by a Physician. Non-priority reports are those that are diagnostic (i.e. labs and radiology reports). Therefore, all Radiology Additional Findings placed in the outguide. The outguide is a folder that is used when the 79 Room. Loose sheets in a patient (ARU) committee. Priority reports are those dictated or written and into was determined many years ago by the Medical Information steps were identified, the process was flowcharted. See Flowchart 6, post printing process. Information was provided by Mary Davidson of Copy reports, interviews were conducted to identify each step of the Radiology and Shirley Percy of the Record Retrieval Unit. Once the In order to determine the routing procedure for Medical Record Methodology pages Results reports are considered non-priority. It should be noted that, according committee. Filed was defined as either attached to the medical record or 11 Although reports are required to be filed within 7 days, in reality, Records Room. to Shirly Percy, there is no representative from Radiology on this they are being filed within 2 days of being received by the Medical Flowcharting: Post-Printing Process (Including Outpatient, Satellite, & Outside Referring Physician Reports) 1s outguide will be transferred to their medical record is not currently on the shelf in the Medical Records Medical Record Copy Medical Record Copy All loose sheets to be filed are categorized as either priority or

87 - MedcaI Record Copy Medical Record Copy (Including Outpatient, Satellite, & Outside Referring Physician Reports) Medical Record Flowchart 6 Copy of Reports 1 pm Day are printed Midnight shift Day 4 Reports are delivered by messenger (bulk) to medical records room Midnight Shift Day Reports are put in - loose sheets bin Morning shift Day 1 Reports are considered nonpriority and are first order sorted Reports are placed 4:3 pm Day 1 on a shelf (8

88 according to Reports are sorted terminal digits Morning shift Day 2-8 am Day 2 Midnight shift Day 1 81 medical record the patient s Report is filed in yes Morning shift Day 2 shelf? record on the Is the medical np put in the medical return record upon its the outguide to be Report is filed in distributed to desks to be filed Reports are terminal digit L) Medical Record Copy (

89 Medical Record Copy medical record upon its return to the Medical Records Room. It is important to note that when a medical record is requested and has not been sent from the Medical Records Room (e.g. when transferred between departments), there may be loose sheets that have not been attached to the record but which are filed in the outguide. Many people are not aware that if they have a patient s record, they can call the Medical Records Room to see if there are any additional loose sheets. If there are loose sheets in the outguide, they will be sent by messenger. Conclusions The post printing process of filing Radiology reports in the medical record is generally accomplished within 2 days. Recommendations As previously explained, a report may be filed but not be in the medical record. Outpatient clinics need to be informed that if a medical record was transferred to them from a location other than the Medica Records Room, they should call to see if there are any loose sheets (e.g. Radiology reports) in the patient s outguide. 82

90 working days (5 outpatient and 2 satellite). See Figure 22, page 84. working days. working days following the procedure. 83 were filed within ten working days following the procedure. A medical record copy was considered filed if it was attached to the medical record or in the patient s outguide. A random sample of 111 reports was taken from all outpatient, outside referring physician, and time, such as checking records after five days. It may be of interest to repeat this study for a shorter period of Recommendations Six of these seven unfiled reports, however, had been printed after 14 medical records and outguides were taken off the filing cabinets and Out of the 111 reports, 7 of them were not filed after ten (November 9-1 1). Ten working days following the procedure, the checked for the presence of the medical record copy of the Radiology This study was conducted to determine if medical record copies Overall, 93.7% of the medical record copies were filed within ten Methodology satellite Radiology procedures performed over a period of three days report. Results Conclusions Procedure to File Time Medica Record Copy

91 % Medical Record Copy Reports Not Posted After 1 Days i..: : J Figure %, N=7 7.69%, N= %, N=15 Outpatnt. Ref. Phys. Satellite Clinics + Clinic

92 Send reports for discharged patients directly to the the reports to return Physicians are sometimes unable to interpret Radiology 85 assist physicians with readings if necessary C Medical Record Room Action: units which then send them to the Medical Record Room variability and reduce theaverage number of days for Radiology results and how to use each Accurately sort and send reports to inpatient units Have an attending Radiologist available at all time to Inform physicians on how to reach the Radiologist Provide documentation of different ways to obtain Action: Action: Action: Study procedure to printing times in order to eliminate sent to one location or the other results from X-rays 7% of the time all reports for 4D North or 4D South are The procedure to printing time has a standard deviation of Radiology sends reports for discharged patients to inpatient 5.7 days Problem: Problem: Problem: Problem: Inpatient Clinics Action Plan C

93 Outpatient Clinics Problem: Some outpatient clinics have time delays as a result of reports being sent to Ambulatory Records Room Action: Send outpatient reports directly to clinic instead of Ambulatory Records Room Problem: 22 of 25 reports (88%) that took over 5 working days were signed by the same Radiologist Action: Study the procedure to printing process in greater detail to identify areas causing delays (in particular, track the Radiologists who are signing the reports and look for trends) Problem: On average, 5.7 working days pass from the date of the procedure until the hard copy report is received Action: Investigate the procedure to printing process in greater detail Problem: Too many steps are required to log onto the Radiology Information System and Pathnet Action: Develop an easier way to access these systems Problem: Physicians are not familiar with all of the available methods to obtain radiology results Action: Inform physicians of all the methods available and instruct them on how to access them Problem: Confusion exists about the name of the patient Action: List the last name before the first name on the report 86

94 Satellite Clinics Problem: The average number of working days for reports to return after an exam is completed at the hospital is much greater than those reports from exams taken at the clinic (13.2 vs. 7.1 working days). Action: Investigate the process from procedure to printing and determine any significant delays Track ultrasound exams (in particular, pregnancy complete ultrasound exams) going to the Northeast clinic Problem: Several reports are returning to the incorrect clinic (e.g. 18% of the reports sent to the Northeast Clinic were for physicians that did not work there) In addition, 13 2% of the reports did not return to the Northeast and Northville Clinics at alt. Action: Look at the process in which the patient information is being entered into the computer Standardize referral forms OR eliminate referral forms and allow the satellite clinics to enter the patient information at the site Have clinics print out their own reports on site or use automated facsimile transmission to distribute reports Have clinics keep one copy of the referral form and monitor the return timeliness and accuracy Review physicians practicing locations for accuracy and update as necessary Review location codes for clinics and eliminate duplicate ones Add the full name of the clinic and the physician code to the hard copy report 87

95 Outside Referring Physicians Problem: Incorrect or missing information regarding physicians name and address and whether they are an inside or outside physician Action: Receptionists need to make sure they are entering this data completely and accurately Problem: More than one doctor number exists for the same physician Action: Before assigning a new doctor number, verify that one has not already been assigned to the physician Problem: It is a hassle for patients to check out films so the outside referring physician can review them Action: Allowoutside referring physicians to sign out their own patients films directly Problem: Physicians call Radiology directly for Radiology information Action: Inform and instruct physicians to use RTAS for a verbal dictation Problem: Reports take longer to return than expected by the outside referring physician Action: Consider using automatic facsimile transmission as a way of report distribution 88

96 Physicians are looking in the patient s medical record for a transferred to them from a location other than the are any loose sheets in the patient s outguide 89 C Medical Records Room, they should call to see if there Inform outpatient clinics that if a medical record was Action: report that is filed in an outguide Medical Record Copy Problem: