History class: How to increase availability of clinical history during interpretation

By clearly defining expectations for clinical histories, using the history gathered by the technologist and establishing a formal system to track compliance, the radiology department at Cincinnati Children’s Hospital Medical Center was able to increase the percentage of radiology exams accompanied by a complete clinical history from less than 40 percent to greater than 90 percent.

The project received a Caffey Award for honorable mention at last year’s annual meeting of the Society of Pediatric Radiology, and a study of the impact of the project was published in the April issue of the American Journal of Roentgenology.

While improved clinical history can benefit radiologist interpretation accuracy, C. Matthew Hawkins, MD, of Cincinnati Children’s, and colleagues found that only 38 percent of radiography studies from their institution’s outpatient and emergency department settings were accompanied by an appropriate clinical history. They considered a clinical history complete if it contained a cause for clinical concern, duration of symptoms and focal site of abnormality, if applicable. It was essentially the what, when and where of the condition being examined.

To boost the percentage of complete histories, Hawkins and colleagues devised a project with five key drivers:

• Establish clear, quantifiable expectations;
• Conduct routine auditing;
• Offer qualitative feedback at the group and individual level;
• Follow up on initial communication of expectations with additional coaching; and
• Gradually increase individual accountability.

“Feedback was initially provided in a general way to the entire group via group performance reports, recognizing the time required even for well-meaning individuals to change ingrained habits,” wrote the authors. “As the project continued, feedback gradually became more detailed and more directed to specific individuals.” They added that direct performance incentives were intentionally avoided early in the project and were discussed only after the group had reached the goal for inclusion of clinical histories.

Hawkins and colleagues noted that the appropriateness criteria for inclusion of clinical history was flexible enough to allow the technologists themselves to include what they thought was appropriate, while remaining specific enough to ensure some standard of completeness.

Before initiating the project, 38 percent of radiography exams were accompanied by a complete clinical history, but this increased to 92 percent by the end of a 15-week improvement phase, according to the authors. Performance was sustained at 96 percent seven months later.