By Dr. David Pastel and Dr. Tessa Cook

As radiologists continue to find themselves challenged by an ever-increasing patient census and decreasing reimbursements, we have sought strategies to deliver more efficient, more effective, patient-centered care.

Here are two examples of how imaging informatics can offer solutions to issues that affect both radiologists and our referring physician colleagues at the beginning and end of the imaging ordering process.



Radiology eConsult (Dartmouth-Hitchcock Medical Center)
Last year, the radiology department at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., launched a new electronic consultation platform that formalizes the traditional “curbside consult.” Radiology eConsults is an electronic consultation service that allows PCPs to ask imaging questions through the hospital’s electronic medical record. The e-consult program enables PCPs to more efficiently and directly communicate with radiology sub-specialists, expediting patient-care decisions while ensuring appropriate image ordering and management of “abnormal findings.”

The eConsult program at Dartmouth-Hitchcock began with a CMMI Health Care Innovation Award. In 2014, Dartmouth-Hitchcock was one of five academic medical centers working with the Association of American Medical Colleges that received a three-year grant to integrate an eConsult program to improve care and contain costs. The grant funded 15 clinical specialties, but did not include radiology. Radiology was added to the service once the hospital recognized radiology eConsult as an important service to improve patient care and manage costs associated with inappropriate imaging requests.

When PCPs have a low acuity imaging question about their patients they simply choose an appropriate subspecialty template and order an eConsult through the EMR. The templates were developed with input from specialists and primary care physicians to ensure that the appropriate data is available for the specialist to give a timely and thoughtful response. All of the radiology templates include the same basic questions with slight variations for the different subspecialties. Once an eConsult is ordered, the completed template lands in the appropriate specialist’s in-basket, who has 72 business hours to respond. Six core subspecialty radiologists handle most of the e-consults at Dartmouth-Hitchcock.

Since the program began in August 2016, the radiology department has received over 60 consultations. Most consultations take less than 20 minutes to complete. A recent survey showed that 86 percent of Dartmouth-Hitchcock PCPs use eConsults and that 95 percent are “very satisfied” with the program underscoring its value. eConsults facilitates engagement of the radiologists in the care of the primary patient and documents daily work done outside of direct image interpretation.

While PCPs and specialists receive RVU credit for generating and responding to eConsults, the service is not yet billable, but is under review by CMS. Until then, the program is more about enhancing radiologists’ value as imagers, not earning RVUs.

ARRTE: The Automated Radiology Recommendation Tracking Engine (University of Pennsylvania Health System)
Penn Radiology developed the Code Abdomen lexicon to more discreetly identify and describe findings of possible cancer that warranted further follow-up. Modeled on the BI-RADS classification for breast imaging, Code Abdomen consists of a numeric category with a description and, when applicable, specification of a test recommendation and timing for follow-up. Code Abdomen was introduced to keep patients from falling through the cracks who need clinically indicated follow-up after an abdominal or pelvic imaging examination.

Structured reporting was used to assist radiologists in including Code Abdomen in their abdominal and pelvic imaging reports. Templates were developed to include menus both for the numeric categories as well as for the possible test recommendations. The templates were periodically reviewed and updated, for example, to accommodate radiologists’ need to recommend additional test types.

To identify patients who had received follow-up recommendations based on their imaging results, the data within the structured templates had to be mined and analyzed. In 2013, ARRTE was developed within Penn Radiology. It includes modules for data validation, compliance checking and follow-up monitoring. ARRTE enters the patients with follow-up recommendations into a queue and monitors for completion of follow-up. If follow-up is not obtained within one month of the recommended time interval, a message is sent to the ordering physician or provider asking for additional information, such as whether they are the correct person to contact, whether or not follow-up is clinically indicated, and reasons why the patient may not have completed follow-up (e.g., additional testing was not desired, the ordering physician disagreed with the recommendation, the finding had already been followed up at an outside facility, etc.). If electronic messages cannot be sent, or responses are not received, the ordering physician is contacted by a follow-up coordinator.

To date, approximately 15 percent of patients undergoing abdominal and pelvic imaging receive follow-up recommendations within our health system. On average, approximately half of those patients have not completed their follow-up within 12 months of the recommendation, and require additional messaging to their ordering physicians to close the loop. ARRTE is maintained by a team of programmers in the Center for Translational Imaging Informatics, under the guidance of Tessa Cook, M.D., Ph.D., and Hanna Zafar, M.D., MHS.

About the authors: Dr. David Pastel is associate professor of radiology and neurology at the Geisel School of Medicine at Dartmouth in Hanover, N.H. He completed his radiology residency and a neuroradiology fellowship at Dartmouth-Hitchcock Medical Center. Dr. Tessa Cook is assistant professor of radiology at the Perelman School of Medicine at the University of Pennsylvania. She is board certified in radiology and imaging informatics, and serves as the director for the Center for Translational Imaging Informatics as well as of the Imaging Informatics Fellowship.