Documentation of radiologist-referrer consults found lacking

Searching three years’ worth of physicians’ notes in their academic medical center’s EMR, researchers at NYU Langone found that many informal consultations between referrers and radiologists had been captured incompletely or inadequately, with potential implications for patient management. In a paper published online in the American Journal of Roentgenology, they recommend radiology practices draw up policies to head off such communications lapses.

Eugene Won, MD, and Andrew Rosenkrantz, MD, entered either “radiology” or “radiologist” in combination with such telling terms as “second opinion,” “overread," “discussed with” and a handful of others in the same vein. From these search results, they constructed a representative cohort of 300 notes describing an informal consultation between a referring physician and a diagnostic radiologist.

Their key findings included:

• Only 18.7 percent of the physicians’ notes indicated the name of the consulted radiologist.
• Of consultations with a local radiologist regarding a specific prior examination, 33.9 percent resulted in a new finding, a change in severity of a previously detected finding or a change in management recommendation.
• Of consultations with a change from the initial report, 24.6 percent were documented by the radiologist via an addendum; 92.9 percent of these addenda agreed with the referring physicians’ notes.

In their discussion, the authors express concern over the infrequent mentions of the consulted radiologists by name and—despite the encouragingly high rate of referrer-radiologist agreement—over the minority of changes documented by radiologists via an addendum.

“Given these findings, solutions are needed to encourage more-complete documentation of informal consultations by radiologists,” Won and Rosenkrantz write. “Although we do not assert that additional documentation is necessarily warranted when a radiologist simply agrees with one’s own earlier interpretation, documentation is required for any communication that may alter patient management.”

Addenda are not always the best way to go, they point out, giving as an example consults that are not related to a specific imaging exam.

“Direct documentation within the patient’s record in the EMR may be one possible solution for such instances, such as through a radiologist’s consultation note stored within the imaging section of the EMR,” the authors write.

Won and Rosenkrantz also suggest radiology practices establish standard procedures for handling documentation of a change in interpretation compared with a report initially provided by a different radiologist.

“Although these may present challenging or uncomfortable situations,” they write, “identifying solutions is valuable not only for radiologists’ own practice but also for patient care.”

Acknowledging their single-site design among their study’s several limitations, they note that, on the basis of their findings, they are working up policies for capturing informal radiologist-referrer consultations at their own institution.