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Automated Incidental Findings Notification Through the Electronic Health Record Utilizing Dictation Macros.

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  • 1University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Avenue, BSH 5056, Cleveland, OH, 44106, USA. tianyuan.fu@uhhospitals.org.

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Summary

Implementing an actionable incidental findings (AIFs) communication workflow using electronic health record (EHR) dictation macros improved radiology report quality and clinician delivery of findings. This system facilitated timely follow-up orders for incidental findings in a multi-hospital setting.

Keywords:
Closed-loop communicationIncidental findingsMacrosQuality improvementRadiology reporting

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Area of Science:

  • Radiology and Medical Imaging
  • Health Informatics
  • Clinical Workflow Optimization

Background:

  • Incidental findings in radiology reports pose challenges for timely clinical communication and follow-up.
  • Existing communication methods can be inefficient, leading to delays in patient care.

Purpose of the Study:

  • To implement and evaluate an actionable incidental findings (AIFs) communication workflow integrated into the electronic health record (EHR).
  • To improve the quality of radiology reports and streamline the delivery of incidental findings to clinicians.
  • To facilitate the ordering of follow-up imaging exams for incidental findings.

Main Methods:

  • Developed standardized dictation macros for various organ systems based on ACR quality measures.
  • Integrated macros into the EHR (Epic) for automated clinician notification and tracking.
  • Monitored alert acknowledgment within 73 hours by radiology operations.

Main Results:

  • Over 12,919 AIFs alerts were filed for 10,766 patients between September 2023 and March 2024.
  • Median acknowledgment time for alerts was 8.1 hours, with 93.9% acknowledged within 73 hours.
  • Follow-up imaging orders were placed for 62.3% of patients identified with AIFs.

Conclusions:

  • A standardized AIFs communication workflow using EHR dictation macros effectively facilitates the delivery of findings and follow-up recommendations.
  • This approach enhances radiology report quality and improves clinical management of incidental findings.
  • The implemented system demonstrated high compliance and efficient communication within a multi-hospital academic health system.