Improving Clinical Histories on Radiology Requisitions

doi:10.1016/S1076-6332(03)80498-1

Academic Radiology

Volume 8, Issue 4, April 2001, Pages 299-303

https://doi.org/10.1016/S1076-6332(03)80498-1 Get rights and content

Abstract

Purpose

The Health Care Financing Administration (HCFA) regards billing for radiologic examinations without an appropriate indication as unlawful, and both the referring physician and the radiologist are liable. HCFA regulations are interpreted as requiring that all requisitions for radiologic examinations include a current diagnosis and appropriate indication for the study. The purpose of this investigation was to determine the rates at which requisitions currently meet these criteria and to assess the effectiveness of a simple intervention designed to improve them.

Materials and Methods

One hundred fifty consecutive chest radiography requisitions were examined to determine the rate at which current diagnoses and appropriate indications were present. An intervention was then implemented that included a month-long effort to inform referring physicians and radiologists of HCFA regulations, followed by a 1-week period during which requested examinations were not performed unless accompanied by a clinical diagnosis and appropriate indication. Another 150 consecutive chest radiography requisitions were then assessed to determine the effect of the intervention. A 3-month follow-up sample of a third set of 150 consecutive requisitions was then obtained.

Results

The intervention produced a 69% decrease in the rate at which current diagnoses were missing from requisitions, and a 61% decrease in the corresponding rate for appropriate indications. Both results are significant with χ² analysis at the P = .001 level. After 3 months with no additional intervention, rates decayed back toward baseline, with only a 35% remaining decrease for current diagnosis and an 18% decrease for appropriate indication.

Conclusion

The intervention performed in this study significantly reduces the rate of noncompliance with HCFA regulations. However, this improvement decays over time if it is not reinforced.

Section snippets

Materials and Methods

The study was conducted at a large academic children's hospital. We evaluated the clinical histories given on requisitions for chest radiography to determine whether they provided a current diagnosis and an appropriate indication for chest radiography. Samples of 150 consecutive requisitions were collected at three points. The first sample took place before the intervention to establish baseline rates of compliance. The second sample took place immediately after the intervention. The third

Results

Prior to the intervention, a current diagnosis was missing in 43 (28.7%) of the 150 requisitions and an appropriate indication was missing in 46 (30.7%). After the intervention, the frequency of noncompliance dropped to 13 (8.7%) and 18 (12.0%) of 150, respectively. This represents a 69% decrease in the noncompliance rate with the requirement for a current diagnosis and a 61% decrease for appropriate indication. By χ² analysis, both results are significant at P = .001.

However, after 3 months

Discussion

Before discussing the results of this study, it is necessary to clarify further the terms “current diagnosis” and “appropriate indication.” What is a current diagnosis? A current diagnosis is the suspected or presumed condition for which the patient is being evaluated at the time of imaging. In the case of inpatient studies, it is important to remember that the current diagnosis and the admitting diagnosis are often not the same. For example, in the case of a patient admitted for a hip fracture

Acknowledgements

The authors thank Martha Hunskor, DO, and Courtney Pierce, BS, for their assistance in data acquisition, Katie Lane for her assistance with statistical analysis, and Barbara Dodds for preparing the manuscript.

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DJ Markert et al.
Effect of computerized requisition of radiology examinations on the transmission of clinical information
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KS Song et al.
Impact of clinical history on film interpretation
Yonsei Med J
(1992)

There are more references available in the full text version of this article.

Cited by (44)

Requests for radiologic imaging: Prevalence and determinants of inadequate quality according to RI-RADS
2021, European Journal of Radiology
To determine the prevalence and determinants of radiologic imaging requests that are of inadequate quality according to the Reason for exam Imaging Reporting and Data System (RI-RADS).
This study included a random sample of 673 radiologic examinations performed at a tertiary care center. The quality of each imaging request was graded according to RI-RADS. Ordinal regression analysis was performed to determine the association of RI-RADS grade with patient age, gender, and hospital status, indication for imaging, requesting specialty, imaging modality, body region, time of examination, and relationship with previous imaging within the past one year.
RI-RADS grades A (adequate request), B (barely adequate request), C (considerably limited request), and D (deficient request) were assigned to 159 (23.6 %), 166 (24.7 %), 214 (31.8 %), and 134 (19.9 %) of cases, respectively. Indication for imaging, requesting specialty, and body region were independently significantly associated with RI-RADS grades. Specifically, routine preoperative imaging (odds ratio [OR]: 3.422, P = 0.030) and transplantation imaging requests (OR: 8.710, P = 0.000) had a higher risk of poorer RI-RADS grades, whereas infection/inflammation as indication for imaging (OR: 0.411, P = 0.002), pediatrics as requesting specialty (OR: 0.400, P = 0.007), and head (OR: 0.384, P = 0.017), spine (OR: 0.346, P = 0.016), and upper extremity (OR: 0.208, P = 0.000) as body regions had a lower risk of poorer RI-RADS grades.
The quality of radiologic imaging requests is inadequate in >75 % of cases, and is affected by several factors. The data from this study can be used as a baseline and benchmark for further investigation and improvement.
Reason for exam Imaging Reporting and Data System (RI-RADS): A grading system to standardize radiology requisitions
2019, European Journal of Radiology
Citation Excerpt :
For instance, the policy implemented by the Centers for Medicare and Medicaid Services (formerly Health Care Financing Administration) requires imaging requisitions to include both a current diagnosis and an appropriate indication for the test [12]. Therefore, lack of such information may put the radiologists, imaging facilities and clinicians at risk of financial loss [12]. Despite being subjected to critical scrutiny, little has been done to change the status quo of the quality of imaging requisition, and most efforts have been focused on computerization of the process [3,17,18].
Radiologists often encounter imaging requisitions that lack important information needed for accurate diagnostic studies. Reason for exam Imaging Reporting and Data System (RI-RADS) is proposed as a grading system for evaluation of the quality of clinically pertinent information provided in imaging requisitions. Three categories of information are suggested as key indicators of quality: impression, clinical findings, and the diagnostic question. This scheme is intended to improve the quality of imaging requisitions and overall patient care.
The Role of Clinical History Collected by Diagnostic Imaging Staff in Interpreting of Imaging Examinations
2019, Journal of Medical Imaging and Radiation Sciences
Requisitions for diagnostic imaging (DI) studies may occasionally contain incomplete, or lack any, clinical information. The value of technologist notes, provided in addition to the requisitions, for interpreting DI examinations has not yet been reported. The purpose of this study is to evaluate if the addition of clinical information in the form of technologist notes assists in interpreting DI examinations and if the impact of these notes depends on the completeness of medical history provided by the referring physician.
The completeness of clinical information in 250 requisitions and the effect of a technologist's notes on radiological interpretation were recorded. The chi-square test was used to evaluate the distribution of outcomes.
Technologist notes were important for interpreting a DI examinations in 69.2% of cases and not important in 30.8%. The notes were significantly more useful for reading radiographic examinations than ultrasound (US) examinations; 52.8% of the requisitions contained full, 25.6% incomplete, and 21.6% did not contain any medical history. Requisitions for ultrasound examinations contained a full medical history more frequently than those for radiographic examinations. The usefulness of technologist notes for both radiographic and US examinations was not different for groups with full, incomplete, or absent medical history.
Technologist notes were important for interpreting DI examinations in more than 2/3 of the cases and were more useful for reading of radiographic than US examinations. Their usefulness did not depend on the degree of completeness of patient history provided in the requisition. Therefore, the addition of technologist notes to clinical information in requisitions is recommended, regardless of medical history provided by the referring physician.
Les réquisitions pour les études d'imagerie diagnostique (ID) peuvent parfois contenir des renseignements cliniques incomplets. D'autres fois, ces renseignements sont tout à fait absents. La valeur des notes des technologues dans l'interprétation des examens d'ID n'a pas fait l'objet de rapports jusqu'à présent. Le but de cette étude est d'examiner si l'ajout de renseignements cliniques fournis par des technologues peut soutenir l'interprétation des examens d'ID et si l'effet de ces notes est influencé par le caractère complet ou non des antécédents médicaux fournis par le médecin traitant.
Le caractère complet ou non des renseignements cliniques de 250 réquisitions et l'effet des notes des technologues sur l'interprétation radiologique ont été enregistrés. Le test du chi carré a été utilisé pour évaluer la répartition des résultats.
L'importance des notes des technologues pour l'interprétation des examens d'ID a été confirmée dans 69,2% des cas (elles n'étaient pas importantes dans 30,8% des cas). Les notes étaient nettement plus utiles pour la lecture d'examens radiographiques que pour celle des échographies. Parmi les réquisitions, 52,8% comprenaient des renseignements complets, 25, 6% comprenaient des renseignements incomplets et 21,6% ne comprenaient pas d'antécédents médicaux. La fréquence des réquisitions d'échographie qui contenaient des antécédents médicaux complets était plus grande que celle des examens radiographiques. L'utilité des notes de technologues était semblable pour tous les groupes, que les antécédents médicaux fournis soient complets, incomplets ou manquants, et ce autant pour les examens radiographiques que pour les échographies.
Les notes de technologues se sont avérées importantes pour l'interprétation des examens d'ID dans plus des deux tiers des cas. Par ailleurs, elles étaient plus utiles pour la lecture d'examens radiographiques que pour la lecture d'échographies. Leur utilité n'était pas influencée par l'exhaustivité des antécédents médicaux du patient dans la réquisition. Ainsi, nous recommandons d'ajouter les notes des technologues aux renseignements cliniques, et ce peu importe les antécédents médicaux fournis par le médecin traitant.
“It's all in the history”: A service evaluation of the quality of radiological requests in acute imaging
2018, Radiography
Citation Excerpt :
The results of this service evaluation project were disseminated via a presentation to foundation doctors in an attempt to improve the local service, as this group generate the majority of requests at our institution. However, it has been shown that the effectiveness of informative campaigns alone reduces over time, for example in the study conducted by Gunderman et al.13 Therefore to bring about a truly sustainable improvement the authors feel that system changes are required and hope that the body of evidence collated in this project will help to influence these. A number of interventions have been proposed to attempt to improve the quality of radiological requests in the literature.
The aim of this service evaluation project was to assess the quality of clinical details provided in radiological requests.
A retrospective review of adult inpatient and emergency department radiological requests over a seven-day period was performed, using the local Clinical Radiological Information System (CRIS). Requests for plain film, CT, MRI and Ultrasound were assessed for the inclusion of a clinical question, lateralisation/localisation of signs or symptoms if required, and relevant past medical/surgical history if available.
1548 imaging requests were analysed. 76% asked a specific clinical question. 74% of requests requiring localisation provided this. Of those cases with relevant past medical or surgical history available, 49% mentioned this. Emergency department (ED) requests provided localisation when required in 81% of cases compared to 62% of in-patients (p < 0.05). However, in-patient requests contained relevant past history in 53% of cases compared to 40% for ED requests (p = 0.00096). Compared to plain film requests, those for CT, MRI and Ultrasound studies were more complete in respect to inclusion of a clinical question (88% versus 72%, p < 0.05), localisation if required (83% versus 71%, p = 0.0007) and pertinent clinical history (67% versus 42%, p < 0.05). Requests from the weekend more often included a clinical question (83% vs 75%, p = 0.00054) and localisation if needed (84% vs 71%, p = 0.00188) compared with weekday requests.
This large-scale service evaluation project shows that the quality of clinical details in requests for radiological investigations requires improvement, particularly in regard to inclusion of relevant past medical and surgical history.
A Failure to Communicate?: Trends in the Radiology Requisition, 2011–2016
2018, Academic Radiology
Complete clinical information improves the diagnostic capacity of medical imaging, and the radiology requisition is the radiologist's primary means of receiving clinical information. This study aimed to characterize trends in the quality of clinical information in radiology requisitions at an academic medical center between 2011 and 2016.
This institution's requisition form includes two questions: “Signs and Symptoms:” and “Clinical Question to be answered…:” Requisitions for three studies (CT UPPER ABDOMEN & PELVIS W, CT HEAD WO, and XR PORT CHEST, 1 VIEW) from three selected months were individually rated in four categories of clinical information. Additionally, requisitions for 13 study types were evaluated for character count and for the proportion of requisitions with identical answers to the two questions. A total of 3250 requisitions were individually rated.
There was a decline in the quality of clinical questions in computed tomography requisitions (P = 0.016) and a decline in the quality of medical history in chest x-ray requisitions (P < .001). Of the 13 study types, nine had more than 1000 total requisitions (total n = 260,617). Of those nine studies, six showed trends of increasing character length (P < .001 for each). Four showed an increasing proportion of identical answers to the two questions (P < .001), and one showed a decreasing proportion of identical answers (P < .001).
This decline in the quality of clinical information is concerning. Whether it is due to increasing time pressures, a shift in the attitudes of ordering providers, or any other cause, this study demonstrates a declining trend in the quality of communication via the radiology requisition.
Managing Incidentalomas Safely: Do Computed Tomography Requisitions Tell Us What We Need to Know?
2017, Canadian Association of Radiologists Journal
Citation Excerpt :
The fact that close to 50% of patients with a history of cancer had that aspect of their clinical history omitted from their requisition is worrying. Lack of clinical information on requisitions is not a new observation [2,3,19]. However, the marked increase in the detection of incidental findings in conjunction with incomplete requisitions presents a recently more prevalent safety concern.
Technological advancements and the ever-increasing use of computed tomography (CT) have greatly increased the detection of incidental findings, including tiny pulmonary nodules. The management of many “incidentalomas” is significantly influenced by a patient's history of cancer. The study aim is to determine if CT requisitions include prior history of malignancy.
Requisitions for chest CTs performed at our adult tertiary care hospital during April 2012 were compared to a cancer history questionnaire, administered to patients at the time of CT scan. Patients were excluded from the study if the patient questionnaire was incomplete or if the purpose of the CT was for cancer staging or cancer follow-up.
A total of 569 CTs of the chest were performed. Of the 327 patients that met inclusion criteria, 79 reported a history of cancer. After excluding patients for whom a history of malignancy could not be confirmed through a chart review and excluding nonmelanoma skin cancer, dysplasia, and in situ neoplasm, 68 patients were identified as having a history of malignancy. We found 44% (95% confidence interval [0.32-0.57]) of the chest CT requisitions for these 68 patients did not include the patient's history of cancer. Of the malignancies that were identified by patient questionnaire but omitted from the clinical history provided on the requisitions, 47% were malignancies that commonly metastasize to the lung.
A significant number of requisitions failed to disclose a history of cancer. Without knowledge of prior malignancy, radiologists cannot comply with current guidelines regarding the reporting and management of incidental findings.
Les progrès technologiques et l'utilisation toujours plus répandue de la tomodensitométrie (TDM) ont permis d'améliorer grandement la détection des constatations fortuites, y compris de minuscules nodules pulmonaires. La gestion de nombreux « fortuitomes » dépend largement des antécédents de cancer du patient. L’étude vise à déterminer si les demandes de TDM comprennent les antécédents de malignité.
Les demandes correspondant aux TDM thoraciques effectuées à notre hôpital de soins tertiaires aux adultes en avril 2012 ont été comparées à un questionnaire sur les antécédents de cancer soumis aux patients au moment de l'examen de TDM. Les patients dont le questionnaire était incomplet ou dont la TDM visait la stadification ou le suivi d'un cancer ont été exclus.
Un total de 569 TDM thoraciques ont été effectuées. Sur les 327 patients qui correspondaient aux critères d'inclusion, 79 avaient des antécédents de cancer. Après avoir exclu les patients pour lesquels il a été impossible de confirmer les antécédents de malignité par un examen du dossier ainsi que ceux qui souffraient de cancers de la peau autre qu'un mélanome, de dysplasie et d'une tumeur in situ, 68 patients ont été définis comme ayant des antécédents de malignité. Nous avons découvert que 44 % (intervalle de confiance de 95 % [de 0,32 à 0,57]) des demandes de TDM thoracique pour ces 68 patients ne comprenaient pas leurs antécédents de cancer. Sur les malignités déclarées dans les questionnaires des patients, mais omises dans les antécédents cliniques fournis avec les demandes, 47 % étaient des malignités qui métastasent couramment au poumon.
Un nombre important de demandes n'indiquaient pas les antécédents de cancer. S'ils ne connaissent pas les malignités antérieures, les radiologistes ne peuvent pas se conformer aux lignes directrices sur la déclaration et la gestion des constatations fortuites.

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¹: R.G.B. supported in part by a General Electric Radiology Research Academic Fellowship from the Association of University Radiologists.

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Original InvestigationsImproving Clinical Histories on Radiology Requisitions

Abstract

Purpose

Materials and Methods

Results

Conclusion

Section snippets

Materials and Methods

Results

Discussion

Acknowledgements

Acad Radiol

Impact of clinical history on film interpretation

Yonsei Med J

Original Investigations
Improving Clinical Histories on Radiology Requisitions