ACTIONABLE FINDINGSIN RADIOLOGY

WhitePaper

The practice of communicating and documenting evidence-based follow-up recommendationsfor actional incidental findings is resulting in a healthcare paradigm shift. This new approach allows potential clinically relevant findings tobe addressed prior to the patient becoming symptomatic, hopefully at an earlier disease stage, enabling a cure.

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ABSTRACT

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Actionable findings are unexpected results that you wish someone to act on. In radiology, these are traditionally incidentally detected, aka “incidentalomas,” or findings identified on imaging exams performed for a different purpose and requiring follow-up imaging. However, they can also be in a different class. For example, a cancer patient has a new, unsuspected metastasis, or the abdominal aorta has increased in size and the radiologist wishes to ensure the referring clinician acts on this information. Follow-up recommendations may include guidance for additional imaging within a timeline advised by guidance, as well as clinical assessments, laboratory testing, therapeutic intervention, or subspecialty consultation. Guidance for the finding may also suggest that no further follow-up is required unless clinical concerns exist or unless the patient’s condition changes.

Actionable information communicated from the radiologist to the referring provider is crucial to coordinating patient care. The importance of this has long been recognized by TJC, AHRQ, Medicare, and other regulatory agencies as a means of improving patient safety. However, actionable incidental findings are generally outside The Joint Commission (TJC) 2006 National Patient Safety Goal [1] which specifies communication mechanisms, timelines, and required documentation only for test results that fall into the critical or urgent category results. Incidental findings rarely fall into either of these categories and can easily be overlooked or inappropriately followed-up. But they may fall into the category of benefiting from personal communication [2].

Because of the importance to patient care and safety, the process of communicating incidental findings and incorporating evidence-based follow-up recommendations have been Medicare quality metrics (MIPS/QPP #364, #405 and #406) for more than 15 years. While the final radiology report will often be available within minutes or hours following exam completion, the American College of Radiology (ACR) found it necessary to introduce (last updated in 2020) a non-routine communication practice [3] to ensure that the report has been reviewed by the appropriate clinician(s) and the important finding(s) appreciated. This personal communication, akin to a handoff, is supported by safety, quality, and medical malpractice thought leaders [2] and has been codified in Pennsylvania Act 112. Act 112 requires outpatient imaging services to communicate directly with the patient within 20 days if a “significant abnormality” is found.The Pennsylvania Medical Society defined this to be “a finding by a diagnostic imaging service of an abnormality which would cause a reasonably prudent person to seek additional or follow-up medicalcare within three months.” TO

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BACKGROUND

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The ACR Actionable Reporting committee divided actionable imaging findings into 3 categories [4] defined by their levels of urgency, which is related to the severity of the findings (Figure 1). The specific names of the categories are less important than the concepts behind them. These 3 categories of actionable findings require, respectively, communication and clinical decision within minutes (category 1), hours (category 2), or days (category 3) [3, 4]. Category 1 functionally maps to TJC critical results and category 2 maps to TJC urgent results. In general, actionable incidental findings fall into category 3. While not all incidentally detected imaging findings are actionable, some incidentalomas require immediate attention, and many, if not most, fall somewhere between those two extremes [2, 4].

The importance of communication and documentation was also emphasized by the Emergency Care Research Institute (ECRI) in a special Information Technology report on closing the loop on diagnostic test results [5]. They found that alerts, audits, data gathering, processes to identify the responsible provider, integrate systems, and automate consultations can be effective for closing the loop on abnormal laboratory tests and medication interactions. The ECRI extended this work in 2019 as guidance on how best to document and communicate incidental imaging findings [6]. Although targeted at the emergency care setting, the ECRI guidance is generalizable to all environments as a best practice. The ECRI recommends [6]: “(1) phone or in-person communication with the ordering provider; (2) communication via phone, US mail, or secure electronic methods with self-referred patients and any primary care or specialist identified by the patient during the intake process; (3) documentation of the communication (to provider, to patient) and any recommendations and decisions on follow-up; and, (4) implementation of a method to track patient follow-up and to identify vulnerability and opportunities for improvement.”

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BACKGROUND

Figure 1. Radiologic Society of North America (RSNA) implementation of the American College of Radiology (ACR) recommendations on documentation of communication of actionable findings [3, 4]. https://radreport.org/home/RPT297/2014-04-06%2000:00:00

(Actionable findings categories defined by: Larson PA, er al. J Am Coll Radiol 2014; published online. DOI 10.1016/j.jacr.2013.12.016)

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INCIDENCE AND ADHERENCE

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The number of incidental findings identified on imaging exams has increased, likely due to heightened awareness of the need to include these in radiology reports as well as the increased utilization of cross-sectional imaging. The increase may also be prompted in part by a move from volume to value for radiologists as well as the reporting requirements and practice guidelines detailed above. Several authors reported incidental findings are present in about one-third of CT reports [7], whereas in 2008 there were 2.5% requested follow-ups in chest radiograph reports [8].

A 2017 systematic review [9] of 20 studies involving 627,000 patients showed large variability in both the distribution of incidental findings and in the prevalence of malignancy for specific organs. The prevalence of incidental findings was highest for computed tomography (CT) of the chest (45%), CT colonography (38%), and cardiac magnetic resonance imaging (MRI; 34%). Prevalence was intermediate for MRI of the brain and spine (about 20% for each) and low for whole-body positron emission tomography (PET) and PET/CT (2%). The percentage of incidental findings that were malignant varied by organ: breast, 42%; ovary, 28%; thyroid, 28%; kidney, 25%; colon, 17%; prostate, 11%; and parotid, 5%. No brain incidental findings and only a few adrenal gland incidental findings were malignant. Lung was not specifically reported on.

The body of evidence, as well as guidelines addressing incidental findings and providing advice on how they should be managed, continues to expand. Most radiologists now are aware of and follow the 2017 Fleischner Society’s guidelines for managing incidentally identified pulmonary nodules [13, 5]. Moreover, the ACR’s incidental findings committee [14] publishes recommendations based both on evidence as well as input from clinically active radiologists and clinical specialists. The guidance documents are contained both in ACR-sponsored white papers (https://www.acr.org/Clinical-Resources/Incidental-Findings) as well as white papers published in JACR.

Adherence to the guidelines is variable, when additional imaging is requested, compliance rates ranged from 30% to 77% [15-13]. This lack of compliance with recommendations has an impact—it can lead to incorrect patient management, poor clinical outcomes, and an increase in medical malpractice risk.For this reason, several studies are summarized here.

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In 2008, outpatient chest radiograph reports (n=29,138) were queried for recommendations for a follow-up CT exam [8]. Of these reports, 4.5% contained this recommendation and 65.4% of patients underwent a chest CT exam within a year of the index radiograph. Another study, also in 2008, found actionable findings identified on outpatient chest radiograph reports (n=1,316) were followed-up by chest CT at a rate of 67% [10] over a 1- to 2-year follow-up window. Concerning findings in abdominal radiology were followed 63% of the time [11] in a different study. And in pediatric radiology, follow-up rates were slightly higher at 69% [12]. Overall, roughly one-third of the recommendations were not followed!

In 2014, Sloan et al. [16] found that 12% (5 of 43) of patients with imaging findings of possible cancer received potentially inappropriate management 3 months after initial detection. The same group reported (in 2019) 37% of patients with findings of possible cancer in abdominal imaging reports did not undergo follow-up imaging within 1 year [17]. Clark and Coats [15] looked at thyroid nodules seen on CT and gallbladder polyps seen on abdominal ultrasound. They found that only 10.5% of incidentally identified thyroid nodules had follow-up as recommended by guidelines. Of the patients (89.5%) where the guidelines recommended no follow-up be performed, all patients underwent follow-up imaging except 2.5% (2.8% adherence). In addition, 20% of the incidental gallbladder polyps were followed-up—more often than either the radiologist recommended (8.8%) or the ACR guidelines recommended (1.25%).

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INCIDENCE AND ADHERENCE

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There are now numerous manuscripts describing both manual and semi-automated actionable finding tracking solutions. In addition to ensuring patients are followed-up, these systems have been used to identify reasons for patient and provider non-compliance with recommendations. In 2015, the University of Rochester [18] manually tracked 3 months of patients with an incidental finding requiring follow-up imaging. A final exam completion rate of 71% was achieved after 13 months. This follow-up tracking resulted in 107 new imaging studies, three-quarters of which were CTs or MRIs. Two Natural Language Processing (NLP) algorithms were then used to help with follow-up. One of the NLP engines gathers exam recommendations from patient reports, and a second used the collected data to send follow-up reminders to the navigator. After implementing the NLP algorithms, a further 29% increase in exam-completion rate resulted.

The University of Pennsylvania [16] manually tracked patients with findings of possible cancer in abdominal imaging reports. As mentioned earlier, in 2014, they found 12% received potentially inappropriate management if their ordering providers were not personally notified of the finding. Reasons for this management included patient loss to follow-up, provider failure to review imaging results, previously known imaging findings, or providers/patients outside the health system. To understand the ordering providers’ perspective, a second group was contacted 5-6 days following release of the final radiology report. At that time, 33% of these providers were unaware of the imaging findings. The ordering providers were also surveyed regarding communication preferences: 75% preferred to be notified of abnormal findings via e-mail or the EMR and 56% wanted an embedded hyperlink enabling immediate follow-up order entry. However, only 25% had a system to monitor whether patients had completed ordered testing.

Next, the University of Pennsylvania [19, 20] developed an automated radiology recommendation-tracking engine for incidental focal masses in the liver, pancreas, kidneys, and adrenal glands. A second phase expanded the capabilities to include additional anatomic structures in the abdomen and pelvis, including the ovaries and the endometrium. The engine used NLP and was dependent on structured reporting to be used in combination with Code Abdomen (a macro that was placed in the radiology report). Code Abdomen enabled monitoring patients with indeterminate (category 0 or 3) or suspicious (category 4 or 5) lesions for malignancy. Category 99 allowed the radiologist to report examinations deemed inadequate. Radiologists were required to use the Code Abdomen system to indicate how concerned they were thata mass could be cancer when dictating all abdominal CT and MRI exams, and relevant ultrasound (US) studies. For indeterminate masses, the radiologist must recommend a modality and time interval for follow-up (for example, CT in three to six months). A separate system, Code Cancer, was used for oncology imaging because of the need to assess more than the four target organs of Code Abdomen (and because there is less chance that a cancer patient will be lost to follow-up).

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PUBLISHED PATIENTTRACKING SOLUTIONS

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A joint program between the University of Washington, Lahey Clinic, and Philips Healthcare created a radiology report processing pipeline [21, 12] to extract follow-up imaging recommendations using an ontology-based approach [22]. Based on 17 months of radiology reports, 27,375 (6.6%) reports were found to have at least one follow-up imaging recommendation sentence. Of these, 4,819 exams contained lung, adrenal, and/or thyroid findings of interest. For example, 3,909 CT Chest exams contained a follow-up recommendation—2,905 (74.3%) of these were lung-related (with lung only findings: 2,775; lung and thyroid: 87; lung and adrenal: 43).

The University of Pennsylvania [17] found emergency department patients who were <40 years or >80 years were less likely to complete follow-up imaging. In contrast, Vanderbilt University [23] found patient education level to be a significant predictor of Lung Cancer Screening patient follow-up on an incidentally identified finding. A greater than high school education was strongly associated with appropriate follow-up, even after controlling for other demographic factors. Whether patient education level is itself significant or whether it is a surrogate for low socioeconomic status or an indication of health literacy could not be differentiated.

The Brigham and Women’s Hospital developed three color-coded levels to indicate the urgency of test results [24]: red for immediately life-threatening problems, orange for results likely to involve mortalityor significant morbidity if not treated urgently, and yellow for findings that are not immediately life-threatening. Red and orange alerts required interruptive communication (conducted by telephone,by pager, or face-to-face) between physicians or other licensed caregivers—not administrative staff. Yellow alerts, however, could be delivered using asynchronous methods (such as email). This approachis a closed-loop system in that the ordering provider must acknowledge receiving each alert. Because they might have more information about the patient than the radiologist can, the ordering provider was allowed to disagree with the radiology recommendation, but must click to do so, making that decision part of the patient’s medicolegal record and closing the communication loop.

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PUBLISHED PATIENTTRACKING SOLUTIONS

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Eon EPM provides a complete end-to-end Actionable Findings module that closes the communication loop on required follow-up documentation and further enables tracking longitudinal follow-up to close the clinical loop and ensure patient care and capture.

While every facility has a slightly different workflow, Eon EPM integrates with any EMR and RIS (radiology information system). Eon EPM automates documentation of demographics, radiology report features, actionable patient tracking, patient and referring provider letters, and pathology correlation in addition to risk-based follow-up management including referral to specialist physician review.

The Actionable Findings module identifies candidate radiology reports based on semi-structured NLP, while having the flexibility to incorporate local and regional radiologist dictation preferences. Actionable finding type (category 1, 2, or 3) and physician-to-physician communication are extracted from thereport and documented in Eon EPM. Facilities have the ability to close the patient record knowing the communication loop has been closed or the patient record can remain open until the clinical care has been managed and outcomes have been assessed.

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THE EON ADVANTAGE

01Radiologist Identifies Finding

Eon EPM Adds Finding into Dashboard

Navigator Closes the Loop on Communication

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Radiologist Notifies Ordering Physician About Finding

Communication is Documented

Navigator Activates on Trigger for Next Steps

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How it Works

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Communicating and documenting evidence-based follow-up recommendations for actionable incidental findings has resulted in a healthcare paradigm shift. This approach allows potential clinically relevant findings to be addressed prior to the patient becoming symptomatic, at an earlier stage and time point, and potentially enabling a cure. The use of standardized reporting for radiologists is supported both by the ACR, the RSNA, and other working groups for improved communication clarity. For non-routine findings, peer-to-peer communication is advocated, and if patient’s self-refer or do not have a primary care provider, then direct patient communication is advised by both the ECRI and the ACR. Beyond report structure is the “RADS” (ACR Reporting and Data Systems) approach (e.g., LungRADS for Lung Cancer Screening, BiRADS for breast imaging, etc). RADS provides a standardized framework for reporting imaging findings where consistent numbering across scoring systems easily identifies urgent patient care needs. These highly structured systems along with report templating have allowed language processing solutions to identify radiology reports with recommended follow-up or communication requirements to be identified and these patients to be tracked. Improvements in patient management, as well as pre-identifying patients at risk of not following up, are afforded by Eon’s automated solutions.

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CONCLUSION

IMPROVEMENTS IN PATIENT MANAGEMENT, AS WELL AS PRE-IDENTIFYING PATIENTS AT RISK OF NOT FOLLOWING UP, ARE AFFORDED BY EON’S AUTOMATED SOLUTIONS.

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REFERENCES:The Joint Commission – 2006 Annual Report.Radiology Business Journal -- 2/18/2019, Lincoln Berlin quote.ACR Practice Parameter for Communication of Diagnostic Imaging Findings, 2014.Larson PA, et al. Actionable Findings and the Role of IT Support: Report of the ACR Actionable Reporting Work Group. J Am Coll Radiol 2014; 11: 552-558. http://dx.doi.org/10.1016/j.jacr.2013.12.016ECRI Special Report, “Closing the Loop on Diagnostic Tests: Information Technology Solutions,” Sept 2017.ECRI Research Report, “Managing Incidental Findings on Imaging,” 2019.Adams SJ, et al., "Toward a Comprehensive Management Strategy for Incidental Findings in Imaging," Canadian Family Physician, 62 (2016): 541- 543).Harvey HB, et al. Diagnostic yield of recommendations for chest CT examination prompted by outpatient chest radiographic findings. Radiology 2015; 275:262–271 DOI: 10.1148/radiol.14140583O'Sullivan JW, et al. Prevalence and outcomes of incidental imaging findings: umbrella review. BMJ 2018; 361: K2387. DOI: 10.1136/bmj.k2387Little BP, et al. Outcome of recommendations for radiographic follow-up of pneumonia on outpatient chest radiography. AJR 2014; 202: 54–59 DOI: 10.2214/AJR.13.10888Dalal S, et al. Determining Follow-Up Imaging Study Using Radiology Reports. J Digit Imaging 2020; 33: 121-130. DOI: 10.1007/s10278-019-00260-wMabotuwana T, Hombal V, Dalal S, Hall CS, Gunn M. Determining adherence to follow-up imaging recommendations. J Am Coll Radiol 2018; 15 (3 Pt A):422–428MacMahon H, et al. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017. Radiology 2017; 284(1): 228-243.ACR Incidental Findings:https://w ww.acr.org/Clinical-Resources/Incidental-FindingsClark TJ and Coats G. Adherence to ACR Incidental Finding Guidelines. JACR 2016; 13: 1530-1533. http://dx.doi.org/10.1016/j.jacr.2016.05.008Sloan CE, et al. Assessment of Follow-up Completeness and Notification Preferences for Imaging Findings of Possible Cancer: What Happens After Radiologists Submit Their Reports? Acad Radiol 2014; 21: 1579- 1586. doi:10.1016/j.acra.2014.07.006 Cho JK, et al. Patient Factor Disparities in Imaging Follow-Up Rates After Incidental Abdominal Findings. Am J Roetgen 2019; 212: 1-7. doi.org/10.2214/AJR.18.20083Wandtke B and Gallagher S. Reducing delay in diagnosis: multistage recommendation tracking. Am J Roentgen 2017; 209: 970-975.Licurse MY, et al. Expanding the Scope of an Automated Radiology Recommendation-Tracking Engine: Initial Experiences and Lessons Learned. J Digit Imaging 2017; 30: 156-162. DOI 10.1007/s10278-016-9912-yCook TS, et al. Implementation of an Automated Radiology Recommendation-Tracking Engine for Abdominal Imaging Findings of Possible Cancer. J Am Coll Radiol 2017 May;14(5):629-636. doi: 10.1016/j.jacr.2017.01.024Mabotuwana T, et al. Extracting Follow-Up Recommendations and Associated Anatomy From Radiology Reports. Stud Health Technol Inform 2017; 245: 1090-1094Mabotuwana T, Hall CS, Hombal V, et al. Automated tracking of follow-up imaging recommendations. AJR 2019; 212:1287–1294Kapoor S, et al. Education Level Predicts Appropriate Follow-Up of Incidental Findings From Lung Cancer Screening. J Am Coll Radiol 2020; in press. https://doi.org/10.1016/j.jacr.2019.12.014Lacson R, et al. Four-year impact of an alert notification system on closed-loop communication of critical test results. Am J Roentgenol. 2014; 203: 933-8.

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