Hi fellow CMIOs, CNIOs, and other applied Clinical Informatics friends,
I'm writing today to share some helpful insights into one of those clinical operations things you don't usually learn much about during clinical education and training : Incidental and other actionable findings.
First, some literature review. Before we dive into this, I'd like to share this excellent 2014 groundbreaking paper from the Journal of the American College of Radiology (JACR) Actionable Findings Workgroup, including Larson MD, Berland MD, Griffith MD, Kahn Jr MD, and Liebscher MD:
Also note that the American College of Radiology (ACR) and American College of Emergency Physicians (ACEP) recently published a joint piece in the March 2023 Journal of the American College of Radiology (JACR), an excellent white paper (click here to open it) about "Best Practices in the Communication and Management of Actionable Incidental Findings in Emergency Department Imaging" (Christopher L. Moore, MD , Andrew Baskin, MD , Anna Marie Chang, MD, MSCE , Dickson Cheung, MD, MBA, MPH , Melissa A. Davis, MD, MBA , Baruch S. Fertel, MD, MPA, Kristen Hans, RN, MS, Stella K. Kang, MD, MSc, David M. Larson, MD, Ryan K. Lee, MD, MBA, Kristin B. McCabe-Kline, MD, Angela M. Mills, MD, Gregory N. Nicola, MD, Lauren P. Nicola, MD, JACR Mar 13, 2023). However, since this is an important discussion, I thought I'd share some broader insights into these important workflows from an Applied Clinical Informatics perspective.
It all starts here : In healthcare, there are the routine clinical scenarios, and then there are the unusual, unexpected clinical scenarios. Most of the time, laboratory studies are generally within normal or anticipated ranges, and radiologic studies (X-rays, ultrasounds, CT scans, and MRIs) produce expected or anticipated results.
So when labs or radiology are unanticipated, unusual, or abnormal - they can come in different levels of abnormal :
- Mildly abnormal - Something is unusual that requires special but not-urgent clinical attention (within days)
- Moderately abnormal - Something is unusual that requires urgent clinical attention (within hours)
- Severely abnormal - Something is unusual that requires immediate clinical attention (within minutes)
In all three cases, it's not enough to just deliver the routine results of the lab or radiology to the ordering provider. For patient care and safety reasons, some type of extra communication is warranted.
The three most common reasons for these extra communications all fall under a general category known as 'Actionable Findings' - Note these categories align with the findings from the 2014 JACR Actionable Results Workgroup above :
Now the interesting challenge of these additional communications is the urgency of these additional messages and how they can sometimes conflict with real-world scenarios :
- What if the ordering provider was a resident who has gone home at the end of their shift?
- What if the attending has also gone home at the end of their shift?
- What if both the resident and attending have turned off their phones/pagers or are asleep?
- Who is the covering provider?
- What if the covering provider is busy with urgently caring for another patient?
Since most providers will arrive through your Credentialing/Medical Staff office, and most residents/fellows will go through your Graduate Medical Education (GME) office, you will want to collect this information at onboarding, and help maintain it at regular intervals (e.g. recredentialing or yearly assessments.)