SummaryA county-owned safety-net provider, Parkland Hospital and Health System modified its electronic critical-results reporting system and related communication protocols and workflows so that the surgical oncology clinic, in addition to the ordering provider, receives immediate notification about any patient seen in the emergency department or ambulatory setting for whom imaging results suggest a possible gastrointestinal malignancy. An assigned surgeon at the clinic reviews the results and works with the clinic manager to schedule any needed followup care, without the patient having to first see his or her primary care provider. In its first 10 months in operation, the program significantly enhanced access to specialty care for patients with potential malignancies, with many more patients accessing timely diagnostic workups and treatment.Moderate: The evidence consists of a retrospective comparison of key metrics in patients treated under the new program during its first 10 months in operation, compared to similar patients treated during a 10-month period in the year before implementation.
Developing OrganizationsParkland Health & Hospital System; University of Texas Southwestern Medical Center
Date First Implemented2010
Patient PopulationThe program primarily serves low-income patients, including Medicaid beneficiaries, those covered by local safety-net insurance offered by Parkland, and the uninsured.
Problem AddressedUninsured and underinsured patients who come to safety-net providers with general abdominal symptoms often receive imaging studies to investigate their cause. When these tests reveal a possible malignancy, these patients can face significant delays before they can access appropriate followup care, and by then, any cancer may have metastasized. These delays are caused by the following factors:
- Emergency Department (ED) used as primary care: When care occurs in the ED (which is generally not equipped to handle this kind of primary care1), responsibility for arranging needed followup typically falls to patients, many of whom have little or no idea how to do so.
- Overburdened primary care clinics: When patients are seen in an ambulatory setting, test results go back to the ordering physician to determine appropriate next steps. However, followup appointments at these clinics are often not available for weeks or months.2,3 For example, before implementation of this program, Parkland’s primary care clinics were overburdened, with patients typically waiting many weeks for followup appointments.
- Rapid provider turnover in a training environment: Much primary care at Parkland is handled by residents and fellows, who rotate quickly through different areas of the organization and often leave after their training is complete.4 As a result, the ordering physician for a GI study may pass the followup responsibility on to a new resident or fellow, whose large workload and lack of familiarity with procedures and patients may delay followup.
Description of the Innovative ActivityA safety-net provider, Parkland Hospital and Health System modified its electronic critical-results reporting system and related communication protocols and workflows so that its surgical oncology clinic receives immediate notification about any patient seen in the ED or ambulatory setting for whom imaging results suggest a possible GI malignancy. A designated surgeon at the clinic reviews the results and works with the clinic manager to schedule needed followup, without the patient having to first see his or her primary care provider. Key program elements are outlined below:
- Identifying target cases: The system modification covers patients seen in the ED or ambulatory setting who receive imaging tests in which a radiologist identifies suspicious findings that suggest a possible malignancy. It does not cover patients who have known malignancies, because the primary care providers for those patients are already aware of a malignancy risk. The software allows the radiologist to tag such findings with a “yellow” alert, indicating that the patient needs prompt followup. (“Red” alerts demand immediate followup and are sent to designated personnel even at night and on weekends, whereas “yellow” indicates less urgency and is not sent until the next business day. The protocol for handling red alerts was not changed.)
- Alerting of surgical oncology clinic: For patients whose imaging studies indicate a yellow alert, the critical results reporting system allows the radiologist to send the alert to an assigned surgeon at the surgical oncology clinic as well as to the ordering physician. Messages are sent via pager, smartphone, or e-mail, depending on the preference of the recipient, and the system is able to verify when the recipient reads or listens to the message. Messages not verified within 24 hours are resent.
- Clinical evaluation and referral to case manager: The assigned surgeon in the oncology clinic reviews the image and the patient’s medical record, determines appropriate followup care, and refers the case to the clinic manager.
- Clinic-manager facilitation of needed followup care: The clinic manager contacts the patients and schedules followup, typically starting with a full diagnostic evaluation. After the diagnostic workup, the patient is scheduled for any necessary treatment, including surgery or referral to interventional radiology or gastroenterology.
- Followup with ordering physician: Along with the notification of the initial result, the ordering physician receives notification of the care plan and all the arrangements for its execution.
Context of the Innovation
Owned and operated by Dallas County, Parkland Hospital and Health System is an urban safety-net hospital with 723 staffed beds that primarily serves Medicaid beneficiaries, those with county-sponsored insurance, and the uninsured. A “closed” system in which virtually all primary and specialty care occurs within the organization, Parkland handles 1.2 million outpatient visits and conducts 447,000 imaging studies annually. Parkland operates a level 1 trauma center, 11 primary care clinics, and many specialty clinics. The organization also provides medical student and resident training in cooperation with University of Texas (UT) Southwestern Medical Center, with staff and residents from the medical school working in many of the specialty clinics. Parkland has an almost completely deployed electronic medical record (EMR) system that is used to chart test results, write clinical notes, and conduct most clinical communications. Parkland also has a critical-results reporting system that directly notifies clinicians when a given result needs immediate action.
The impetus for this program came from a lead surgeon in the surgical oncology division of UT Southwestern Medical Center, which receives referrals for all patients with suspected GI malignancies. Concerned that Parkland’s overburdened primary care clinics were responsible for delays in care for patients with suspected GI malignancies, this doctor requested that a way be found to reduce the time between the initial diagnostic imaging test and the patient being seen in the oncology clinic.
ResultsIn its first 10 months in operation, the program significantly enhanced access to specialty care for patients with potential GI malignancies, with many more patients receiving timely diagnostic workups and treatment.
Moderate: The evidence consists of a retrospective comparison of key metrics in patients treated under the new program during its first 10 months in operation, compared to similar patients treated during a 10-month period in the year before implementation.
- Better access to specialty care: During the program’s first 10 months in operation, 98.0 percent of the 49 patients with potential GI malignancies saw a specialist, more than twice the 45.9-percent rate among 61 similar patients during a 10-month period in the year before implementation. Those served by the program waited a median 7 days to see the specialist, compared with 35 days before the program began.
- Enhanced access to diagnostic workups and treatment: Among the same patient cohorts, the proportion of patients completing a diagnostic workup increased from 77.1 percent before the program began to 93.9 percent afterwards, with the median time to completion falling from 44 to 18 days. The proportion of patients who had management increased from 72.1 percent to 89.8 percent, with the median time to initiation falling from 62 to 35 days.
- Undetermined impact on costs, specialist workflows: The program’s impact on costs and specialist workflow has not yet been determined. By immediately referring patients to specialty care, the program has the potential to raise costs, increase care fragmentation, and disrupt specialist workflows, because some patients with benign conditions not requiring specialist care end up being seen by specialists. Anecdotally, surgical oncologists report that these patients do not pose a major burden, since the time required to evaluate them is minimal.
Planning and Development Process
Key steps included the following:
- Evaluating options, choosing strategy: A workgroup consisting of representatives from radiology, primary care, surgical oncology, and the ED collaborated to evaluate strategies, including expanding primary care clinic capacity and implementing a short-stay, rapid workup program in the hospital. The team ultimately chose to revamp the critical results reporting system to alert the oncology clinic at the same time as the ordering provider, as this strategy could be implemented quickly at minimal cost.
- Revamping system to create surgical oncology contact: Information technology (IT) staff revamped the system to add a generic contact address at the surgical oncology clinic to the critical results system database. Named “clinic, surgical oncology,” this address was initially assigned to the head of the clinic. However, the address can easily be reassigned to another individual as necessary (e.g., to accommodate personnel changes or vacations), by sending the new e-mail address or pager/telephone number to the IT resource person responsible for the results-reporting system.
- Executive oversight of workflow changes: The hospital system’s division vice president and the medical director of the radiology department oversaw the workflow change and the accompanying research on its effectiveness (as described below).
- Retrospective chart review to evaluate impact: To determine the program’s impact, the team reviewed cases involving “yellow” GI malignancy messages sent during the first 10 months after implementation of the new protocol, and compared them with similar cases from the corresponding 10 months of the previous year, when results were sent to the ordering physician but not the surgical oncology clinic.
Resources Used and Skills Needed
- Staffing: The program requires no dedicated personnel, as existing staff incorporate program-related activities into their regular job responsibilities. As noted, the radiology manager selects the relevant messages to be routed to the surgical oncology clinic, whereas the assigned surgical oncologist reviews those cases and works with the clinic manager to arrange appropriate followup and communicate back to the ordering provider. This time generally represents a shift to caring for patients earlier, rather than an increase in the total time spent on such care. The program required a small amount of IT staff time upfront to create the system contact "Clinic, Surgical Oncologist" in the results reporting system.
- Costs: This program requires little or no incremental costs, as it uses existing personnel and builds on Parkland’s existing EMR and critical results reporting software.
Funding SourcesUniversity of Texas Southwestern Medical Center; Parkland Health & Hospital System
Getting Started with This Innovation
- Leverage existing communication systems: The program builds on existing electronic communication systems, including an EMR system and critical results reporting software.
- Consider use in “closed” systems: This program will work best in a “closed” provider system in which primary, emergency, and specialty care are all provided by one organization that shares a common electronic communications infrastructure. Consequently, it may be most applicable to integrated delivery systems, including accountable care organizations.
- Win support of ordering physicians: Ordering physicians may react negatively to the idea of patients going directly to specialists, feeling they are being “cut out” or that their “turf” is being invaded. To avoid this problem, explain the proposed protocols to them and set up the system to ensure they remain in the loop from a communications perspective throughout the process.
Sustaining This Innovation
- Be gentle with patients: Patients can be easily alarmed by a call from a surgical oncology clinic to schedule a workup, especially if the finding of possible GI malignancy was incidental to the main reason they had the imaging study in the first place. Consequently, clinic personnel charged with scheduling appointments should be instructed to be sensitive to this possibility and deal with patients accordingly.
- Look for expansion opportunities: Once the program proves successful in one area, hold meetings with specialists in other areas to see if there may be opportunities to use critical results reporting and proactive specialist followup to improve the timeliness of appropriate care.
Contact the InnovatorTravis Browning, MD
Department of Radiology
UT Southwestern Medical Center at Dallas
5323 Harry Hines Boulevard
Dallas, TX 75390-8896
Innovator DisclosuresDr. Browning reported receiving consulting fees from McKesson Enterprise Medical Imaging Group and Hewlett-Packard through VisionIT. These consulting fees were not related to the work described in this profile.
References/Related ArticlesBrowning T, Kasper J, Rofsky NM, et al. Quality improvement initiative: enhanced communication of newly identified, suspected GI malignancies with direct critical results messaging to surgical specialist. BMJ Qual Saf. 2013;22:168-75.
Lasser KE, Kronman AC, Cabral H, et al. Emergency department use by primary care patients at a safety-net hospital. Arch Intern Med. 2012;172:278-80. [PubMed]
Munk MD, Peitzman AB, Hostler DP, et al. Frequency and follow-up of incidental findings on trauma computed tomography scans: experience at a level one trauma center. J Emerg Med. 2010;38:346-50. [PubMed]
Singh H, Thomas EJ, Mani S, et al. Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: are electronic medical records achieving their potential? Arch Intern Med. 2009;169:1578-86. [PubMed]
Pincavage AT, Ratner S, Prochaska ML, et al. Outcomes for resident-identified high-risk patients and resident perspectives of year-end continuity clinic handoffs. J Gen Intern Med. 2012;27(11):1438-44. [PubMed]
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Original publication: December 04, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: December 04, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.