The American College of Radiology (ACR) is a non-profit, professional society with over 30,000 members, consisting of radiation oncologists, radiologists, and clinical medical physicists. Their primary purposes are: advancing the science of radiology, improving radiologic services to patients, studying socioeconomic aspects with regards to radiology, and encouraging continuous study in radiology and medical physics, as well as associated fields.
They periodically define new practice parameters and procedures in order to advance the field of radiology and improve the quality of service to patients. The following is a summary of the most recent document regarding the proper communication of diagnostic imaging findings. Source: ACR Practice Parameter for Communication of Diagnostic Imaging Findings Res. 11 – 2014.
Preamble
The document is a tool for practitioners to help them in providing appropriate care. None of the parameters are fixed, nor should they be used as the legal standard of care; therefore, it is encouraged that the guidelines not be used in the case of litigation.
Where standards of care deviate from those described in the parameters, it does not imply the standard of care was sub-par. Where a course of action deviates substantially, practitioners are encouraged to document their reasons for doing so.
Adherence to ACR guidelines does not guarantee an accurate diagnosis based on the complexity of the human condition. A practitioner should, however, always follow a reasonable course of action based on the most current knowledge and resources available, and according to the needs of the patient. The sole purpose of the document is to help practitioners deliver the safest and most effective care.
I. Introduction
“Effective communication is a critical component of diagnostic imaging.” The most appropriate methods of communication should:
- support healthcare providers in delivering the best patient care possible
- be timely
- minimize the risk of error
The timely exchange of reports between interpreting and referring physicians is important. All healthcare providers share a responsibility with regard to obtaining imaging studies they have requested, while imaging interpretation needs commitment from all concerned.
If possible, previous reports need to be available for comparisons with current studies. A request for imaging needs to include all relevant data pertaining to the patient.
II. Diagnostic imaging reports
A final report needs to be drawn up and archived after all parameters have been met. This is done by the interpreting physician. The completed report needs to include certain applicable information.
A. Components
The suggested content for an imaging report is as follows:
1. Demographics: facility name, patient name, names of all physicians and relevant healthcare workers, examination type, date, and time. Additional items which could be included in this section are date of dictation, transcription date and time, patient’s date of birth, and gender.
2. Relevant clinical information
3. The body of the report should:
- contain a description detailing all the procedures that have been performed, the administration of any and all pharmaceuticals, and/or all devices used on the patient (if not noted elsewhere)
- include all findings
- indicate any and all factors that may have influenced the examination
- address any and all factors pertaining to clinical questions
- include a comparison with relevant studies or reports where applicable
4. Impression, conclusion, or diagnosis: when possible, the report should contain specific diagnosis. When appropriate, a differential diagnoses should be included, as well as follow-up studies. Any patient reaction which is deemed significant should also be noted.
5. It is advised that any standardized, electronic template reports also follow this same format.
B. Principles of Reporting (Final Report)
The final report:
- is the final documentation of the results pertaining to a medical imaging procedure or examination
- needs to be proofread
- should be completed within the parameters as set out by the relevant state and federal requirements (electronic date stamps and - electronic signatures are acceptable where state law allows and such devices are deemed secure)
- should be transmitted to the ordering physician/healthcare provider in accordance with relevant state and federal requirements (the ordering physician/healthcare provider shares in the responsibility for obtaining the results of imaging studies)
- should accompany the transmittal of relevant images to other healthcare professionals as requested, when feasible
- should be copied and archived by the imaging facility and be available for future reference (any retention and distribution of such records are to be in accordance with state and federal regulations, as well as facility policies)
C. Other communications (not including the final report)
1. The preliminary report:
- is not always used, but will precede the final report when needed
- serves to direct immediate patient management or meet the needs of a particular environment
- is likely to include limited or incomplete information
- may be communicated verbally, electronically, or in writing (all forms of communication should be documented)
- should be reproduced into permanent format, then correctly labelled and archived
In the event that there are significant differences in findings or conclusions between the preliminary and final report, those differences need to be reported to the ordering physician in such a way as to ensure the communication is received, especially when it will have an impact on patient care. The communication of such discrepancies should be documented in the final report.
2. Non-routine communications
When a non-routine situation arises, the interpreting physician should expedite the delivery of the report (preliminary or final) to the ordering physician. Depending on the nature of the findings, if the intended recipient cannot be contacted, the results of the imaging study may be communicated directly to the patient.
(i) Situations in which non-routine communication might be warranted:
- findings that could require immediate or urgent intervention
- findings that vary from a previous interpretation when failure to act in a timely manner could adversely affect the patient
- findings that the interpreting physician believes may be harmful to the patient’s health and might not require immediate attention, but could result in an adverse outcome if they get worse over time
(ii) Documenting non-routine communication
All forms of non-routine communication should be documented by the interpreting physician and placed either on the radiology report or patient’s medical record. They may also be entered in a department log or personal journal in order to serve as a history.
(iii) Methods of non-routine communication
Any method of non-routine communication should be handled in such a way that it reaches the recipient in a timeframe that will provide the maximum benefit to the patient. Verbal communication, whether via phone or in person, is considered appropriate. Other forms of communication are also acceptable, as long as they confirm receipt of the message and comply with HIPAA and state and federal laws. Methods such as e-mail, voice messaging, texting, etc. may not necessarily guarantee receipt, although they may be considered.
3. Informal communications
On occasion, an interpreting physician will be asked to give an interpretation that does not result in any form of report, but could serve as advice for the ordering physician regarding patient treatment. This type of communication has risks involved and those who are asked to provide this type of consulting are encouraged to document such instances.
III. Self-referred and third-party referred patients
The majority of patients are referred by a healthcare professional; however, for some imaging procedures, patients are self-referred or referred by a third party such as their employer or insurance provider.
A. Self-referred patients
Performing imaging studies on such patients forms a doctor-patient relationship which includes the responsibility to communicate the results directly to the patient to arrange for the appropriate follow-up.
B. Third-party referred patients
Patients may also be referred by insurers, employers, federal benefits programs, and lawyers. The results are often first communicated to the third party or its designated clinician who then shares them with the patient. The interpreting physician is responsible for ensuring the patient is informed of any serious or unexpected findings and may convey them to the patient directly.
IV. Communication policies
A communication policy is effective with regards to promoting patient care, and can provide guidance on:
- the types of communication deemed critical
- those responsible for delivering and/or receiving communication
- appropriate communication methods
As technology and communication methods evolve, actions need to be taken to accommodate those changes, while still remaining in compliance with state and federal law, as well as local requirements. According to HIPAA, patients have the right to access their personal health information. The ACR therefore advises that patients are allowed access to all imaging reports. This can be accomplished in a variety of ways, one of which is through a web-based portal. When selecting the method for sharing medical images, the best interests of the patient as well as the relationship between the patient and ordering physician should be considered.
Changes over the years
When the first edition of this document was published in 1991, it was referred to as a “Standard.” This terminology remained through the 1995, 1999, and 2001 revisions before it was changed to a “Guideline” in 2005. Finally, in 2014, this was once more edited to a “Parameter.” While the main points of the documents remained relatively consistent throughout each revision, there were some more noticeable and substantive changes between 2005 and 2010, as well as 2010 and 2014.
The primary difference in the 2005 and 2010 revisions is the definition of the final report. For quite some time, this was considered the definitive communication to the ordering physician. It has been found, however, that interpreting physicians have a duty to communicate any unexpected findings as soon as possible, so the 2010 revision instead considers the final report as the definitive documentation of imaging study results. As more responsibility is placed on radiologists to ensure their reports are communicated to the ordering physicians, the guideline serves to give radiologists the tools for handling these communications. The rapid growth in IT helps facilitate communication and aids in reducing malpractice risks. Regardless of the communications methods used, however, all should be documented, in the report and/or other medical documents, stating the date, time, contact person, method of communication and information exchanged.
The difference in the 2010 and 2014 revisions pertains to communication policies. The 2010 version states that communication methods should continue to evolve while still following the recommendations set out in the guideline, whereas the 2014 version specifies that all means of effective communication should comply with federal, state, and local statutes as well as developing legal guidelines. Furthermore, it mentions that patients have a right to access their personal health information. The ACR recommends that imaging reports be made available to them, through a web-based portal, for example. It goes on to say that whatever communication method(s) are chosen should always keep the best interests of the patient and the patient-physician relationship in mind.