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    Article from: Winter - 2020

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    By Pam McGrath

    Closing the Loop: MIR Creates a Safety Net for Patients with Incidental Findings

    Closing the Loop

    Above: MIR’s follow-up program is currently tracking incidental findings from radiology reports at Barnes-Jewish and Barnes-Jewish West County Hospitals but will expand to Barnes-Jewish St. Peters and Progress West Hospitals during the program’s second grant year.

    After falling and hitting the back of his head in August 2018, Kent Kiplinger found himself in the Barnes-Jewish Hospital emergency department. A head and cervical spine computed tomography (CT) scan didn’t indicate a concussion, but it did reveal something else: a mass the size of a silver dollar in the frontal lobe of Kiplinger’s brain.

    Andrew J. Bierhals, MD

    Above: Andrew J. Bierhals, MD, serves as the project lead of the follow-up program. He and Paula Grow, the project’s nurse coordinator, work to eliminate the potential of “important information being lost, or transmitted but unseen,” Bierhals says.

    That incidental finding, included in the report submitted by a radiologist at Mallinckrodt Institute of Radiology (MIR), prompted a call to Kiplinger from Paula Grow, a registered nurse and the coordinator of MIR’s incidental finding follow-up program. She encouraged him to undergo a follow-up magnetic resonance imaging (MRI) scan. Upon following her recommendation, he was diagnosed as having a benign meningioma. With no easily identifiable symptoms — Kiplinger only later realized his sense of smell had diminished — the tumor could have eventually reached his optic nerves.


    A Program to “Seal the Cracks”

    Kiplinger is one of 60 to 70 patients a week who benefit from MIR’s incidental finding follow-up program, established in January 2018. The program’s goal is to close the loop between the time MIR radiologists identify and report incidental findings on imaging scans to when next-step actions are taken — whether that means scheduling another scan, visiting a primary-care physician or seeing an appropriate subspecialist.

    “Today’s health care is so complex that patients have fractionated care,” says Andrew J. Bierhals, MD, associate professor of radiology and vice chair of quality and safety. “In the past, primary-care physicians would admit their patients to the hospital, visit them there, write orders and then see them back in their offices. Today, primary-care physicians no longer see their patients once they are hospitalized; instead, hospitalists and a team of experts care for patients, thus creating multiple patient records. The potential for important information being lost, or transmitted but unseen, by those who need to take further action is substantially increased.”

    MIR’s follow-up initiative, supported by a grant from Coverys Community Healthcare Foundation, has uncovered a startling statistic — 15% of the patients or physicians contacted by the program’s coordinator are unaware of the incidental findings reported by MIR radiologists.

    “According to an Institute of Medicine quality and safety report, the process for reporting incidental findings on imaging scans is not complete until the patient and their family, or someone acting in their best interest, is made aware of and is taking action on those findings,” says James R. Duncan, MD, PhD, professor of radiology and chief of interventional radiology, who helped secure the Coverys grant. “What sets our program apart is that we not only inform patients and physicians about incidental findings, we take seriously the Institute of Medicine’s recommendation of making sure follow-up occurs.”


    Paula Grow with James R. Duncan, MD, PhD

    Above: Paula Grow, (left), shown with James R. Duncan, MD, PhD, personally connects with patients and physicians by phone to ensure any incidental findings are communicated and next steps established. Other follow-up programs exist that use text or email, but “a busy physician may receive hundreds of electronic communications a day,” says Bierhals.


    An Epic Resource

    Bierhals and Grow have worked closely with representatives of the electronic medical records (EMR) software system Epic to develop a radiology template that flags scans requiring follow-up communication. Working from a list generated in Epic, Grow acts as a patient-advocate detective.

    “The template prompts MIR radiologists to describe the incidental finding, recommendations for follow-up and a timeframe for that follow-up,” says Grow. “Starting with the most urgent first, I contact the physician who ordered the scan, the patient’s primary-care doctor or a nurse or medical assistant in the medical offices to make sure they have received the radiology report and recommendations.”

    If a patient is seen in the Barnes-Jewish Hospital emergency department, for instance, and no primary-care physician is listed, Grow contacts the patient directly to explain the radiologist’s findings and help them take the next steps toward follow-up care.

    “A personal phone call ensures there is direct, one-to-one communication with someone who can take responsibility for further action on behalf of the patient,” says Bierhals. “Programs exist at other institutions that focus on sending notifications by text or email. The complication is a busy physician may receive hundreds of electronic communications a day. Sifting through those to identify important messages about their patients can be time-consuming and overwhelming.”

    Whereas radiology follow-up programs at most other institutions stop at the point of notification, MIR is one of just a few in the nation to take it a step further. Grow keeps track of radiologists’ recommended timeframes for follow-up on each patient; when that deadline is reached, she again contacts the physician’s office or patient to find out what actions have been taken.

    “In cases where an incidental finding involves, for instance, identifying a new tumor in a patient already being treated for cancer, I’ll track the oncology notes in a patient’s EMR to see if there’s mention of the radiologist’s finding,” says Grow. “If not, then I take the precaution of making a personal phone call to the oncologist or a staff member.”

    After contacting a physician or patient two to three times without further action being taken, Grow sends a certified letter outlining the incidental finding and the radiologist’s recommendation. Only then does she consider the case closed.


    pulmonary nodules

    Above: The follow-up program’s grant proposal focused specifically on pulmonary nodules (shown in scan at left) and masses due to the frequency in which the they are found incidentally.

    Expanding the Program at BJC HealthCare and Beyond

    In the program’s first year of grant funding, incidental findings on radiology reports from Barnes-Jewish Hospital and Barnes-Jewish West County Hospital are being tracked. In the grant’s second year, plans call for rolling out the program to the community-based Barnes-Jewish St. Peters Hospital and Progress West Hospital, in St. Charles County and O’Fallon, respectively.

    “At the end of the grant cycle, we foresee having developed a follow-up program that can easily be implemented by other institutions using the Epic EMR system, or that can be modified and incorporated into other EMR systems,” says Bierhals. “Effectively communicating incidental findings is a recognized challenge for hospital groups throughout the country. We feel the program we are developing features the elements most important to closing the patient-care loop: namely, personal, one-to-one communication and repeated follow-ups that ideally result in actions that promote quality diagnoses and treatments for our patients.”

    Through the follow-up program, Kent Kiplinger was referred to Michael R. Chicoine, MD, the August A. Busch Jr. Professor of Neurological Surgery at Washington University School of Medicine. After surgery in June 2019 and a two-week hospital stay, Kiplinger went home — tumor-free.