Friday, August 05, 2011

Why Radiologists Should Review Reports Carefully , and Why Health IT Causes Screwups

Another way computers in medicine can lead to maimed and dead patients:
Why Radiologists Should Review Reports Carefully
Diagnostic Imaging
By Arun Krishnaraj, MD | August 2, 2011

Mrs. Anderson called her doctor and spoke with pressured speech: “I think there is a mistake. That cannot be my ultrasound. I don’t have a gallbladder.”

Mrs. Anderson was accessing our hospital’s open EHR, which allowed her to view her radiology reports, and noticed a discrepancy. An ultrasound had been performed which identified “multiple hypoechoic lesions, incompletely characterized.” Because the lesions discovered were indistinguishable from metastatic deposits by ultrasound an MRI was correctly recommended for more definitive characterization. However, the dictating radiologists overlooked a “canned” normal finding in his final report noting the presence of a normal appearing gallbladder. Mrs. Anderson’s gallbladder had been removed surgically 10 years prior.

[In other words, he ticked a "normal" box or template and out came the report of a normal gallbladder - ed.]

Mrs. Anderson’s case came to my attention when I dictated her liver MRI, comparing it to the ultrasound performed earlier in the week. The liver MRI fortunately demonstrated only multiple benign lesions. My report commented on expected post cholecystectomy changes in the right upper quadrant in the findings of the dictation but not in the impression.

I did not read the portion of the prior ultrasound report describing the gallbladder because I was only concerned with the positive finding for which the MRI had been ordered, the liver lesions.

[In other words, most doctors are too busy and distracted by their work to have to deal with computer-generated garbage - ed.]

I received an e-mail the next day from the nurse practitioner (NP) caring for Mrs. Anderson. She said that Mrs. Anderson had called her office frantic that there was some kind of mix up and that her patient wanted to know which of her reports were correct. I reviewed both reports and realized there was a proofreading error on the ultrasound report, paged the dictating radiologist to amend the error, and explained to the NP how such errors occur with our speech recognition software and macros.

[They're lucky this case was not like the infanticide by computer cases
here. However, next time, luck may run out and a critical finding might be missed, or an incorrect one added that results in catastrophe - ed.]

The NP understood and said she would explain to Mrs. Anderson that both her studies were accurate except for the oversight on the ultrasound dictation which would be amended.

While the NP realized how such errors may make their way on to finalized reports, I now better understand the impact an incorrect report can have on a patient. [My mother could have told him this, but he'd need a megaphone to talk to her. Her incorrect report has caused her to change her address to a cemetery and she is now six feet under the ground - ed.]

We are entering a new era of health care that is more patient centered. Part of this new paradigm is patient access to their medical records, easily accessible from the Internet.

While physicians possess the ability to distinguish between an occasional proofing error, patients can not, nor should they be expected to.

[And when physicians fail for any reason to distinguish such errors, patients are put in harm's way - ed.]

In order to increase the efficiency of radiology reporting, most institutions have moved to speech recognition (SR) software with templated macros. The potential for typographical errors has been shown to be higher using SR software than traditional transcription services.1

[Wait - technology is supposed to, through cybernetic magic, reduce errors - ed.]

However, there is a paucity of literature regarding how often errors occur because of the use of pre-populated macros. I learned first hand how my words can affect a patient’s mental well being by inducing unnecessary anxiety. More and more pressure is being placed on radiologists to increase their RVUs to maintain their salaries. However, patients will not and should not excuse us from errors in what we report.

In an era of more open access to all medical records, including radiology dictations, it will be critical for radiologists to take pause and examine their finalized reports carefully.

[1] J Digit Imaging. 2008 Dec;21(4):384-9. Voice recognition dictation: radiologist as transcriptionist.

That might be sage advice for all doctors using computer-based equipment.

-- SS


pillguy said...

I would encourage anyone inputting a significant amount of information into a computer to become a very effective typist. This may sound beneath healthcare providers, but I see no better way to ensure what you want is documented properly in an EHR.

InformaticsMD said...

pillguy said...

become a very effective typist ... I see no better way to ensure what you want is documented properly in an EHR.

I think far more important is that the facilitators of healthcare (e.g., IT personnel) support the enablers of healthcare (clinicians) through appropriate software engineering for mission critical settings.

For example, the facilitators should design IT that has high levels of usability and good fit to specific clinical environments, that does not lose data, and uses the incredible levels of computational power and understanding of computational linguistics, knowledge representation, guideline automation, etc. to facilitate healthcare provision by the clinicians.

As far as typing goes, see the post on medical scribes on this blog. I think using scribes a far better way to leverage clinicians' time than using them as clerk-typists, like you might see in a Sears catalog from the 1940's of the order fulfillment rooms.

-- SS