It is not uncommon for radiologists to receive inadequate patient information that potentially compromises their diagnostic decision-making abilities and accuracy. The recent evidence-based study has shown that communication of clinical information to the radiologist, including patient complaints and indications for the imaging request, is required for a quality radiology interpretation process and for making recommendations. A 2021 study looked at more than 300 orders for MRI and CT exams and found that requisition indications were incomplete 81 percent of the time. Other studies noted that 72 percent of the time radiologists needed more clinical information than they received, and 87 percent felt that additional clinical information could change or modify the final report. It is important for radiologists to receive information that helps them arrive at interpretations that are consistent with clinical findings.
The process for formulating radiological imaging interpretations can be improved by giving reading radiologists accurate clinical context at the time of order entry. Having ready access to clinical context helps radiologists eliminate assumptions and better positions them to apply their skills and expertise in rendering final interpretive reports. The types of pertinent clinical information to be provided by the ordering physician include the patient’s surgical history, major medical conditions, relevant family history, social history (such as drugs, alcohol, or smoking), working diagnosis, signs and symptoms, and questions to be answered. Although there is no standardized protocol, the American College of Radiology mentions that such information can assist the reading radiologist to enhance the clinical relevance of the final report.
Challenges for Radiologists
Many times, radiologists are unaware that a patient’s clinical health information is missing when preparing to interpret a study and dictate a report. A challenge for radiologists can be searching for important information (for example, accessing an EHR requires a system user sign-on, password, and training to maneuver to the patient clinical information) while balancing the pressure to keep pace with a large volume of assigned studies. Another challenge facing radiologists in interpreting studies for multiple hospitals or ambulatory centers, each with its unique EHR system. This results in the need to have access to and knowledge of multiple medical record systems. Radiologists are faced with a daily conundrum: Their desire to obtain the complete clinical context of the reason for an imaging study can interrupt the reading process due to the need to track down clinical information in an EHR. Depending on skill and experience levels, radiologists may voluntarily and inadvertently, assume the risk of a potentially inaccurate study interpretation by not taking the time to search for clinical health information not provided at the time of order entry.
Guidelines for Complete Clinical Information to Radiologists
Following guidelines can help you to avoid misinterpreted radiology studies that might happen due to lack of knowledge of a patient’s clinical information:
- Integrate radiologists into the healthcare team. If findings are not consistent with clinical information provided by the ordering physician, radiologists should initiate a conversation to analyze the situation and determine the next steps in the diagnostic process.
- Encourage radiology technologists to look for and validate the presence of patient clinical information needed at the time of the order. Direct them to collect the information or alert the radiologist if it is not present.
- Engage in an education effort to inform referring providers from inpatient, emergency department, and ambulatory locations of the evidenced-based benefits of providing the pertinent or even critical patient information needed for the interpretation and reporting of imaging studies. Offer the ordering provider the developed checklist or protocol of information needed at the time of the order.
- Validate and provide ongoing monitoring of radiologists’ access to and knowledge of maneuverability in the EHRs of facilities that originate orders.
- Investigate the digital capabilities of EHRs or other third-party software in using data extraction technology or artificial intelligence to mine information (e.g., clinical health history, family history, surgical history, social history, and current symptoms and complaints) and report information missing at the time of the radiology order. These system capabilities minimize the need for the referring provider to re-enter information that is already in the EHR and efforts by the radiologist to search for important information prior to interpreting and reporting on the resulting study.
- Audit the frequency of radiology orders in your organization that have missing or incomplete patient clinical information. Compare the orders to the information in the patient’s EHR. Identify individual case examples in which missing clinical information would have been beneficial to interpretation, regardless of whether it would have changed the interpretation. Inform ordering providers about consistently missing clinical information and identify those who may need additional education.
- The collection and reporting of a patient’s comprehensive clinical health picture at the time of provider ordering is proven in evidence-based studies to have a positive impact on the quality of the radiological interpretation. This important handoff of patient information from ordering provider to interpreting radiologist can enhance efforts to deliver safer patient care.
Note that the guidelines suggested above are not rules, do not constitute legal advice, and do not ensure a successful outcome. If you feel like you are lost in documentation or need help in bringing accurate reimbursements then you can contact us for medical billing services. MedicalBillersandCoders (MBC) is a leading medical billing company providing complete revenue cycle services. To know more on how we can improve clinical documentation for radiology claims, contact us at info@medicalbillersandcoders.com/ 888-357-3226.
FAQs
1. Why is complete clinical information important for radiologists?
Complete clinical information helps radiologists make accurate interpretations and recommendations by providing context for the imaging study. It ensures that diagnoses are aligned with clinical findings, improving the quality and relevance of radiology reports.
2. What are the common challenges radiologists face in obtaining clinical information?
Radiologists often struggle with missing or incomplete clinical information, navigating complex Electronic Health Record (EHR) systems, and working with multiple hospitals or centers with different EHR systems, all while managing a large volume of studies.
3. How can healthcare providers ensure radiologists receive complete clinical information?
Healthcare providers can implement protocols to ensure that essential clinical details, such as surgical history, symptoms, and family history, are included at the time of the imaging order. Engaging radiology technologists and educating referring physicians can also help.
4. What role does the Electronic Health Record (EHR) system play in providing clinical information?
EHR systems can assist by providing easy access to clinical history, including family and social history, symptoms, and surgical details. Improving EHR technology and integrating AI or data extraction tools can help identify missing information and reduce the need for manual searches.
5. How can outsourcing medical billing help improve radiology claims?
Outsourcing medical billing to experts like MedicalBillersandCoders (MBC) ensures accurate coding, proper documentation, and timely submission of claims. This reduces the likelihood of errors, ensures correct reimbursement, and helps maintain a smooth revenue cycle. Contact us at info@medicalbillersandcoders.com / 888-357-3226 for more details.
