Problem Statement

1. Title: Reinventing the Radiology Wet Read in the Digital EraNames: Alvin J. Yamamoto, MD Mary Ellen Tobey, RTInstitution: NSMC

2. Problem Statement The current communication process used for urgently requested radiology exams (wet reads) utilizes a handwritten form that is manually faxed to the referring office. The current process of communicating wet reads is inefficient, inconsistent, and is now unnecessary due to recent implementation of a speech recognition dictation system that allows radiology results to be available on LMR within 5 minutes. Problems with the current process can lead to delays in diagnosis or medical error. 2

3. Team Members Team Leaders Alvin Yamamoto, MD NSMC Radiology Mary Ellen Tobey, RT NSMC Radiology Team Members Darlene Bevan, RT Diagnostic Supervisor, Salem Hospital Susan Parker, RT Diagnostic Supervisor, Union Hospital Mukesh Rana, Enterprise Imaging Manager Lori Jackson, Transcription Systems Administrator Coaches Christine Blaski, MD NSMC Pulmonary and Critical Care Medicine, Barbara Corning-Davis, NSMC Director of Operational Improvement 3

4. Sponsors Executive Sponsors Mitchell Rein, MD, CMO, Sr. VP Medical Affairs, NSMC Jennifer Costain, VP, Performance Improvement & Patient Safety, NSMC Project Sponsors M. Christian Semine, MD, Chairman of Radiology, NSMC Peg Houghton, MM, RT, Administrative Director of Radiology, NSMC

5. Process Map No – routine film Pt checks into radiology Wet read? Yes – X- ray obtained Tech scans form into PACS Pt leaves dept Tech faxes form to office Tech flags case on PACS Tech picks up form Tech brings form to rad Rad reads case Rad dictates case Rad fills out WR form 5

6. Process Map No – routine film Pt checks into radiology Wet read? Yes – X- ray obtained Tech scans form into PACS Pt leaves dept Tech faxes form to office Tech flags case on PACS Tech picks up form Tech brings form to rad Alternative process #1 Faxes report to office Rad reads case Rad dictates case Rad fills out WR form Tech does not pick up form Tech prints report off LMR 6

7. Process Map No – routine film Alternative process #2 Pt checks into radiology Yes – tech calls results Wet read? No – tech does nothing Yes – X- ray obtained Tech scans form into PACS Abnormal? Pt leaves dept Tech faxes form to office Tech flags case on PACS Tech picks up form Tech brings form to rad Alternative process #1 Faxes report to office Rad reads case Rad dictates case Rad fills out WR form Tech does not pick up form Tech prints report off LMR 7

8. Cause & effect diagram IT Radiologist Internet problems Delayed interpretation Delayed transcription Radiologist tied up Fax problems Inconsistent info on WR and final report Inefficient wet read process PACS problems RIS problems No EMR Schedule delays EMR time consuming Technical problems WR as “reminder” to f/u pt “Just order everything” as wet read Study incompletely processed Forgot to pick up/fax WR Referring office Technologist

9. Baseline data

10. Baseline data

11. Baseline data

12. Supporting Data 12

13. AIM Statement Reduce the average wet read turnaround time for adult outpatient x-rays by 25% by May 2012. 13

14. Measures Measure: Volume of wet read requests Turnaround time from x-ray to faxed report Patient population: Adult outpatients (excludes pediatrics, inpt, ED) X-rays (excludes CT, MRI, U/S) Calculation methodology: Wet read TAT = Time x-ray result faxed – time x-ray completed Time to dictation = Time x-ray dictated – time x-ray completed Data source: Radiology Information System (RIS) Picture Archiving and Communication System (PACS) Data collection frequency: Daily between Jan-May 2012 14

15. Prioritized List of Changes (Priority/Pay-Off Matrix) High Impact Low Easy Difficult Ease of Implementation • Eliminate inconsistencies • with current process • Radiologist/tech calls in • results • Transcriptionists manually • fax wet read reports • Automated fax of results • Techs and rads work faster • Have offices access • reports through LMR • E-mail or pager • notification • Encourage providers to request fewer wet reads 15 15

16. Proposed intervention • Automated fax of radiology reports • Fax automatically sent after radiology report completed in voice dictation system • In event of fax failure notification email is sent to 6 radiology dept personnel • In event of complete system failure, downtime process reverts to handwritten wet reads • Communication of any critical result occurs by verbal communication or Vocada Veriphy in accordance with radiology department and Partners policy 16

17. Old wet read form

18. New wet read form

19. Data Collection Plan 19

20. Change Data (SPC) Intervention

21. Change Data (SPC) Pre-intervention mean TAT 44 min Post-intervention mean TAT 15 min Intervention

22. Conclusions • Automated fax intervention was successful • Average wet read turnaround time for adult outpatient x-rays was reduced by 66% • Handwritten wet read form is no longer necessary • Inconsistencies in the communication process were eliminated • Improvement in patient care 22

23. Next Steps/Plan for Sustainability • Seek additional efficiencies • Implement with pediatric x-ray wet reads • Apply process to other modalities • Continue follow up with referring offices 23