Six Reasons Why You Should Digitalize Incidental Findings Management
Care gaps, such as incidental findings present complex challenges to healthcare organizations and can lead to rising risk for patients. For example, approximately 35 percent of incidental findings that require follow-up do not receive it, often leading to serious adverse outcomes and unnecessary costs. However, not all incidental findings merit aggressive follow-up.
Simply put, an “incidentaloma” (also known as incidental finding) in diagnostic imaging is an abnormal finding unrelated to the original reason for the exam. The reality is that incidental findings management today is not so simple and includes many challenges:
• Determining which incidental findings are material and if they require follow-up
• Lack of standardized report vocabulary and structure
• How do we track findings that require a follow-up a year from now?
• Who owns the role of follow-up?
• Closing the loop to see if the follow-up occurred
• How do we manage and minimize the health and legal risks?
Here is one approach on how to overcome these challenges.
1. To follow-up, or not to follow up, that is the question
The quality of imaging studies has improved considerably with advances in technology. In an article in the British Journal of Radiology, a systematic review determined that 23.6 percent of imaging studies have an incidental finding. Nevertheless, the same study determined that 35 percent of incidental findings in diagnostic imaging required follow-up, which never occurred.
A digitalized solution can close the loop on incidental findings and other care gaps; and help to develop and enhance best practices as part of a continuous cycle
Management of these findings from identification to the follow-up can be problematic. Questions arise. Is the incidental finding even useful? Which findings require follow-up at all?
Best practice is the answer. Guidelines for incidental findings should be chosen from an established medical society, health system, academic center of excellence, multi-specialty physician group or hospital designed in accordance with the best practices associated with the needs and resources within their specific community. These guidelines need to be digitally integrated in the healthcare process and technology system as part of both the imaging workflow and referring physician’s electronic medical record (EMR).
2. An incidentaloma by any other name…is still a challenge to manage
“Secondary variants. Unexpected or off-target results. Unanticipated or unsought-for or unrelated findings. Abnormalities – existing, potential, or suspicious. All names given to the phenomenon described by the term ‘incidental findings', and none without criticism,” says the authors of an article in the European Journal of Human Genetics.
In addition, there is no standard terminology or report structure in diagnostic imaging. Digitalization can help. Implementing natural language processing (NLP) via artificial intelligence (AI), along with structured and unstructured data can help uncovering and identifying incidental findings and other gaps in care.
3. Sometimes you have to put off till tomorrow what you can’t do today
How do you manage an incidental finding follow-up that needs to happen three, six, or twelve months from now, or a serious adverse outcome results? Compounding this is the challenge of tracking and managing multiple findings for multiple patients. According to an article in Diagnostic Imaging, “Basic radiology reporting systems do a decent job of addressing things that can kill a patient in a few hours or week; however they don’t do as good a job at things that might kill a patient in five years.” What do we do without an attached urgency?
An ideal solution would enable digitalized reminders to the appropriate ordering physician and the primary care physician, combined with a digitalized worklist that helps the care team track, evaluate, prioritize, and act on important incidental findings for all of their patients. Better still is a solution that can integrate reminders and work lists into the electronic health record (EHR) for a more holistic patient view and a simplified user experience.
4. Whose role is it anyway?
Incidental finding management can become an uncomfortable game of hot potato, particularly in the U.S. Healthcare is fragmented due to the large number of disparate EMR systems, frequent insurance company changes, and system leakage of patients. In most cases, the burden falls on the doctor that ordered the scan. What if the incidental finding appears in a report ordered in the ER?
In the ideal world, a digitalized solution would enable a care coordinator to manage findings and assist with hand-offs and referrals to the primary care and appropriate specialist for follow-up. In an integrated health system, the information would be shared via a cloud-based application or integrated into disparate EMRs. The hand-off process would vary depending on the make-up of the healthcare organization, but digitalization would lend a consistency in access to incidental finding worklists and visualization of actions.
5. If follow-up occurs in the forest, how do you know it happened?
The Mammography Quality Standards Act (MQSA) requires a mammography medical outcomes audit, resulting in systematic collection and comparison of mammography results with outcomes data. Alas, for almost all other types of imaging exam, radiologists may never know if the incidental finding follow-up occurred.
Closing the loop on follow-up and outcomes helps the radiologist gain more knowledge and further develop their best practice. Today, however, such feedback is generally not available.
A digitalized solution can help ordering physicians, care teams, and radiologists gain insight for better collaboration and trust. In medicine, most physicians seek to perfect their craft. This requires knowledge gained from outcomes and communication of results and actions. A digitalized solution can close the loop on incidental findings and other care gaps; and help to develop and enhance best practices as part of a continuous cycle.
6. Risky business
What is the cost of not following up on incidental findings or other gaps in care? Physicians and care teams are concerned about preventive risk management and achieving the best outcomes for patients. There is also a malpractice risk.
If a large abdominal aortic aneurysms (AAA) is seen as an incidental finding in a radiology exam, it can immediately be referred to a surgeon. But what if the AAA is small, not requiring immediate action, but monitoring and follow-up? What if the incidental finding occurs in an exam ordered by an oncologist who ordered a CT scan to rule out cancer for a patient? If the outcome to the patient is adverse, it can increase risk exposure to the health system and connected physicians.
A digital solution might help to reduce both health risk and legal risk. Such a solution can provide documentation of actions taken combined with appropriate supporting evidence for the decision, such as best practices and standards of care. A comprehensive, end-to-end solution can support the infrastructure for incidental finding management and possible reduce the risk for all.
Proactive follow-up of care gaps such as incidental finding management can play an important role in the transformation of care delivery, by improving quality, safety, and outcomes, while increasing appropriate volume for imaging services. A digitalized, end-to-end management solution has the potential to close care gaps, support strong care collaboration and data sharing, and improve outcomes while reducing cost.