Introduction	Choose Top of pageABSTRACTIntroduction <<Materials and MethodsResultsDiscussionReferencesCITING ARTICLES

Recently, timely and accurate communication of acute or critical results has become a focus through-out medicine, including radiology. The need for this communication has been highlighted by the Joint Commission, which reported the root cause of nearly 70% of sentinel events was poor communication [1, 2]. The American College of Radiology updated its policy on the communication of diagnostic imaging findings in 2005 and stressed the importance of communicating and documenting communication of results [3].

Inadequate communication of critical results is the cause of the majority of malpractice cases involving radiologists in the United States. Several studies have shown that a failure of communication is a causative factor in 70–80% of malpractice lawsuits [4–10]. These lawsuits have progressed even though a radiology report was provided in a timely fashion in 75% of cases, and in many cases the radiologist either contacted or attempted to contact the ordering physician but failed to document this communication.

The patient safety concerns and medical–legal ramifications have revealed an urgent need for information systems that help radiologists communicate results efficiently, in a timely manner, and with appropriate documentation. This article documents the creation and implementation of a comprehensive customer service system to accomplish these goals and the results of this implementation.

Materials and Methods	Choose Top of pageABSTRACTIntroductionMaterials and Methods <<ResultsDiscussionReferencesCITING ARTICLES

A comprehensive customer service program was created in the radiology department of a large, free-standing children's hospital with nine off-site imaging locations. The customer service program is composed of both human and computer resources.

First, customer service representatives were hired to answer all telephone calls to the radiology department and place outbound telephone calls for the radiologists. There are no qualifications to be hired as a customer service representative beyond having a high school diploma. Each customer service representative receives on-the-job training on how to use the documentation system. Currently, seven customer service representatives are employed by the department and staff the reading room from 7:00 am until 11:00 pm every day of the week. The customer service representatives work in a central area in the main reading room within the department. At 11:00 pm, the outpatient clinics close and all studies originate from the emergency department or an inpatient location. It is the duty of the on-service radiologist to communicate all critical findings during the overnight hours. It should be noted that although some critical results are communicated to the emergency department in our hospital, the vast majority are communicated through timely dictation. The emergency department has asked not to be notified by telephone about all positive findings.

Second, a novel workflow management system was created to facilitate the day-to-day operations within the radiology department. This workflow management system has multiple functions, including providing a real-time worklist for the reading radiologist, providing a means through which to ask for communication of results, and providing a site to document all communications. The design and implementation of the workflow management system have previously been reported [11].

The key component of creating a comprehensive customer service program was linking the referring clinicians, radiologists, and customer service representatives. This was accomplished by creating an interface between the workflow management system and the clinical order entry systems. After this interface was created, the request for communication could be initiated by either the referring clinician or the radiologist and facilitated on either end by the customer service representative.

At the time of order entry, the referring clinician can request that the result be called back regardless of whether findings were normal or abnormal, expected or unexpected (Fig. 1). When the study is seen by the radiologist in the workflow management system, a telephone icon is present indicating that the report will be called back to the referring clinician once it is dictated (Fig. 2). The radiologist then views the images and dictates the report. Once the report is signed, it appears on the worklist for the reading room assistant (Fig. 3). The assistant is then able to take action on the report. The workflow management system displays the telephone numbers for the referring clinician as well as the dictated report (Fig. 4). There are fields to document that a communication was attempted or completed as well as a field to document to whom the results were conveyed (Fig. 5). If after hearing the results the referring health care provider would like to talk with the reading radiologist, the customer service representative transfers the telephone call to the reading room. The customer service representative is also able to send a fax of the complete dictated report, if requested.

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Fig. 1 —Screen capture from computerized order entry system shows that the ordering physician has the option to request that results be called regardless of the imaging findings (arrow). This option is available for all inpatient and outpatient radiology orders.

The customer service representatives have specific guidelines on how they are supposed to communicate results. First, they are instructed to contact the ordering provider by the provider's preferred contact method, either via pager or office telephone number. If the customer service representative is unable to contact the ordering provider at the preferred number, the instructions are to contact the provider via alternate numbers. If after multiple attempts the ordering provider still cannot be reached, the customer service representative is instructed to contact another responsible health care provider in the ordering physician's practice. The customer service representative documents each attempt at communication.

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Fig. 2 —Image from workflow management system shows a call has been requested on this specific patient. The call request is indicated by telephone icon (arrow).

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Fig. 3 —Screen capture shows the customer service representative worklist. Patients on the upper half of the screen require a result to be called. Patients on the lower half of the screen have been reserved by a specific customer service representative. Often, reserved cases are actively being called or the customer service representative is awaiting a call-back from the paged physician.

In some instances, a report containing an error is communicated to the ordering provider. In these cases, when an addendum is dictated or a correction is made to a trainee's report, the customer service representative communicates the corrected report to the ordering provider.

Communication can also be initiated by the radiologist. If after reading a study the radiologist determines that there are findings that need to be communicated, the radiologist is able, through a single-button click, to notify the customer service representative that the specific study has results that need to be communicated (Fig. 6). In this instance, the radiologist is able to request that the results be conveyed by the reading room assistant as detailed previously or the radiologist can request that they directly communicate with the referring clinician. In either instance, the communication is documented in the workflow management system.

The detailed communication log is available within the radiology department, and the database can be queried. The database can be used either to provide documentation that a communication has taken place or to provide statistics on the number of communications from the department. To show the frequency that this solution was used, the number of studies with conveyed results was recorded and compared with the total number of studies within the department.

Results	Choose Top of pageABSTRACTIntroductionMaterials and MethodsResults <<DiscussionReferencesCITING ARTICLES

Between the implementation of the comprehensive customer service program in our department on August 1, 2005, and June 1, 2009, 116,844 radiology results have been conveyed to the referring clinician and documented in the workflow management system. This accounts for more than 14% of the 828,516 radiology studies performed in this time frame.

Although the annual number of studies has increased over this time frame, the percentage of conveyed results has not significantly changed (Fig. 7). In 2005, 13.8% of results were conveyed, whereas in the first half of 2009, 13.4% of results were conveyed. No cases were unable to be communicated to the ordering health care provider or a proxy.

Documentation of these communications has proven critical in multiple cases in which the timing of the communication or even the communication itself has come into question. This documentation has been used to mitigate referring clinicians' complaints about communication failure.

Discussion	Choose Top of pageABSTRACTIntroductionMaterials and MethodsResultsDiscussion <<ReferencesCITING ARTICLES

There are several components of the customer service program that we believe are novel, particularly in their combination. First, hiring customer service representatives has helped to improve the efficiency of radiologists and referring clinicians. Radiologists in our department are no longer required to answer or make telephone calls regarding results. The calls are answered by a customer service representative and triaged to the appropriate radiologist. This frees the radiologist from answering calls and allows him or her to continue reading studies. This also becomes more efficient for referring clinicians because they now have one telephone number to call to reach any reading radiologist.

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Fig. 4 —Screen capture of work page for customer service representatives. The left side of the screen provides patient demographic information, communication options for ordering and primary care physicians, and name and telephone number of reading radiologist. The right side of the screen provides the dictated report.

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Fig. 5 —Screen capture from customer service representative contact log. This page allows the customer service representative to document all communications. In this example, communication has already been logged on the bottom half of the image. A date and time stamp is automatically placed on all logged communications. Customer service representatives can enter more than one communication. This is shown as being in progress on the upper half of image.

The customer service representative is charged with reading results of radiology studies to the health care provider and documenting this communication. This provides a common location and source of documentation of communication of results. If the health care provider on the telephone would like more detailed results, he or she can either request a faxed copy of the full dictated report or can quickly be transferred to the reading radiologist. These capabilities allow the department to hire customer service representatives without prior medical training.

The link between the clinical order entry system and the workflow management system is a key component of the customer service program, and we believe it is crucial in providing a satisfactory experience for our referring health care providers. This step allows the referring physician to request results regardless of their outcome or urgency. This feature helps to address the belief that a critical result does not necessarily mean a study with a positive finding but can include a study in which a result is needed as soon as possible.

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Fig. 6 —Screen capture of single-click buttons at the top of every patient's file within the workflow management system. Buttons from left to right allow the radiologist to request doctor-to-doctor communication (icon of two people, not selected in this example) or that results be communicated to ordering clinician (telephone icon). Additionally, the clock icon notifies the radiologist that patient is waiting so that when results are communicated, they can be then conveyed to patient. The printer icon allows the radiologist to print patient information quickly.

Although the importance of communicating critical results has been highlighted by the Joint Commission and the American College of Radiology [1–3], there is no standard definition of a critical result in radiology [12]. Thus, each hospital is required to develop its own definition of a critical result. As part of our customer service program, we have broadened our definition of a critical result to include any result that is communicated. We believe this definition and the resultant communication of more than 14% of our total studies goes beyond the expectations created by the regulatory bodies.

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Fig. 7 —Graph shows that as average number of studies read per month (bars) has increased, the average number of reports conveyed per month (line) has also increased. The percentage of reports conveyed has remained stable since implementation of comprehensive customer service program.

We have not performed a cost-effectiveness study; however, we believe that this customer service program has been cost-effective. Although there is significant cost associated with employing customer service representatives, this cost is offset by the improved efficiency of radiologists [11]. The customer service representatives have helped to create a more satisfying work environment and have played a role in radiologist recruitment and retention.

Since the creation of our workflow management system, other products providing documentation of communication have become available. These products offer many of the same benefits described in our system. The two major differences between commercially available systems and our system are the link to the clinical order entry system and having an in-house group of customer service representatives. Having internal customer service representatives allows all telephone calls to be answered and generated from a single source. This has benefits for both the referring clinicians and the radiologists.

The largest limitation of this system is that it does not account for communications created outside of its confines. There are at least two types of communications that are not documented in this manner: communications initiated by the radiologist outside of the workflow management system and face-to-face communications (in the reading room or at interdisciplinary meetings). In general, the radiologist-initiated communications are documented in the dictated report whereas face-to-face communications are more difficult to track and are generally thought to be significantly underreported.

It would be difficult for any system to document each of these informal communications. One possible method to include these clinical discussions would be to place a customer service representative in each reading room and have them attend each conference. Although this strategy would help to document more communications, it would increase the cost and decrease the efficiency of the customer service program because the customer service representatives would have to become decentralized and more representatives would have to be hired.

The creation of a comprehensive customer service program has been crucial in helping our department comply with our duty to notify referring clinicians of critical results. We believe that the method described has not only been cost-effective but has also provided a high level of service to our referring clinicians while at the same time complying with regulatory and legal requirements. Having both a centralized human element and a widespread computer-based component has been critical to this system's success.