D.18 RAD SERVICE OPERATIONS VACO.pdf

Radiology Online Guide

VETERANS HEALTH ADMINISTRATION

VHA NATIONAL RADIOLOGY PROGRAM OFFICE

i

TABLE OF CONTENTS

1 Diagnostic Services Organizational Structure

2 VISN Lead Radiologist Duties and Responsibilities

3 Standard Operating Procedures

3.1 Orders Management

3.1.1 Modification of Orders

3.2 Scheduling

3.2.1 Future Orders

3.2.2 Urgency

3.3 Utilization Review and Protocolling

3.3.1 CT Protocols

3.3.2 MRI Protocols

3.4 Communication of Results

3.4.1 Results Communication Policies /Medical Center Memoranda (MCM)

3.4.2 Diagnostic Codes

3.4.3 Method of Imaging Results Communication

3.4.4 Critical Imaging Results

3.5 Medical Record Entry and Retention

3.5.1 Radiology Report Retention

3.5.2 Images

3.5.3 Asbestos Standards/Pneumoconiosis Screening

3.5.4 Releasing/Importing Images and Reports

3.5.5 Informed Consent

3.6 Joint Reporting and/or Archiving of Exams in the EHR and PACS

3.6.1 An Imaging Study Registered in the Radiology Package Requires Two LIPs for Interpretation in the Radiology Package

3.6.2 Two Providers Redundantly Reporting or Overreading the Same Report . 15

3.6.3 Radiology Service Provides Technical and Professional Services for an Exam or Procedure Performed by Another Clinical Service

3.6.4 Radiology Service Provides Technical Services Only for an Exam or Procedure performed by Another Clinical Service

3.6.5 Another Clinical Service Stores Images in PACS, With No Other Professional or Technical Services Provided by Radiology Service ii

3.7 Radiology and Nuclear Medicine Report Correction

3.7.1 General Considerations for Radiology Report Correction

3.7.2 Radiology Report Correction Policies

3.7.3 Radiology Report Addenda

3.7.4 Preliminary Radiology Reports

3.7.5 Radiology Report Retraction

3.7.6 Security Keys for Report Retraction

3.7.7 Radiology Report Amendments Initiated by a Veteran or Patient

3.7.8 References for Radiology Report Correction

3.8 Radiology and Nuclear Medicine PACS Image Correction

3.8.1 General Considerations for Correction of PACS Images

3.8.2 PACS Image Correction Policies and Procedures

3.8.3 Correct Exam of Correct Patient Sent to PACS Under Incorrect Order / Accession Number

3.8.4 Correct Exam of Correct Patient, However Images Sent to PACS With Wrong Annotation or Other Image Errors

3.8.5 Incorrect Exam or Site Performed on the Correct Patient

3.8.6 Images Sent to PACS Associated to Wrong Patient

3.8.7 Incorrect Patient Examined

3.8.8 Appropriate Security Keys to Delete Images From PACS

3.8.9 References for Correction of Images in PACS

3.9 Silver, Lead, and Medication Disposal

3.10 CD Disposal

3.11 Quality Assurance and Process Improvement

3.11.1 Quality Improvement (QI) Committee

3.12 Use of Equipment for Purposes Other Than VA Patient Care

3.13 Breast Ultrasound

3.13.1 Personnel standards for screening and diagnostic breast ultrasound

3.13.2 Equipment standards for screening and diagnostic breast ultrasound ... 31

3.13.3 Reporting standards for screening and diagnostic breast ultrasound

3.13.4 Ultrasound-guided breast intervention

3.14 MRI Cardiac Implantable Electronic Device Guidance

3.14.1 Definitions

iii

3.14.2 MR Nonconditional Devices

3.14.3 Patient Referral and Confirmation of Exam Appropriateness

3.14.4 Adherence to CIED Identification and Evaluation

3.14.5 Exam Scheduling and Patient Screening / Prep

3.14.6 Adherence to CIED Requirements for MRI Examination

3.14.7 Assessment and Programming of the CIED Before and After Imaging .. 36

3.14.8 Appropriate Patient Monitoring and Adverse Events

3.14.9 Special Considerations for Implantable Cardiac Loop Recorders

3.14.10 Follow-up

3.14.11 Reference

4 Contrast Agents

4.1 Orders for Contrast Agents

4.2 Medication Reconciliation

4.3 Supervision of Contrast Administration in the Radiology Service

4.4 Documentation of Contrast Administration

4.5 Use of Low Osmolar Contrast Medium (LOCM)

4.6 Use of Contrast Warmers

4.7 Risk Factors for Iodinated Intravascular Contrast

4.8 Safety Screening for Oral Contrast Agents

4.9 Safety Screening for Iodinated Intravascular Contrast

4.9.1 Laboratory Testing

4.9.2 Contrast Induced Nephropathy (CIN)

4.9.3 Timing of Repeat Iodinated Contrast Administration

4.9.4 Metformin

4.9.5 Prior Contrast Reaction and Allergies

4.9.6 Recent Meal

4.9.7 Relative Contraindications

4.9.8 Pregnancy

4.9.9 Patients Who Are Breastfeeding

4.10 Safety Screening for MR Contrast

4.10.1 Nephrogenic Systemic Fibrosis (NSF) Risk Stratification

4.10.2 Screening/Laboratory Testing

iv

4.10.3 GBCM Selection and Protocol

4.10.4 End-Stage Renal Disease Patients on Chronic Dialysis

4.10.5 Prior Contrast Reaction

4.10.6 Metformin

4.10.7 Gadolinium Retention Related to GBCM Administration

4.10.8 Gadolinium Based Contrast Media Medication Guides

4.10.9 Pregnancy

4.11 Informed Consent Specific to Contrast

4.11.1 Definition of High Risk

4.12 Adverse Events

4.12.1 Extravasation

4.12.2 Contrast Reactions

4.13 Premedication Strategies for Patients with Prior Contrast Reactions

4.13.1 Elective Premedication

4.13.2 Emergency Premedication

4.14 Hydration Protocol

5 Radiation and MRI Safety

5.1 Personnel Dosimetry and the Radiation Worker

5.2 Pregnant Employees

5.3 Inspection of Personal Shielding Devices

5.4 MRI Safety

5.4.1 MRI Safety Training

6 Policy Links and Useful Program Information

6.1 Mammography

6.2 Radiology Information Systems and PACS

6.3 Workload and Productivity

1 DIAGNOSTIC SERVICES ORGANIZATIONAL STRUCTURE

Last Reviewed/Updated: 6/5/2018

The National Radiology Program (NRP) is one of two programs that make up VHA Diagnostic Services (10P11D). Organizationally, Diagnostic Services reports to Specialty Care Services (10P11), which is under the direction of the Deputy Under Secretary for Health for Policy and Services. Each of the program offices under Diagnostic Services is led by a physician Director, who in turn reports to the Chief Consultant, Diagnostic Services.

2 VISN LEAD RADIOLOGIST DUTIES AND RESPONSIBILITIES

The VISN Radiology and/or Diagnostics ICC Clinical Lead works with the Diagnostics ICC Co-Lead, ICC Committee and subordinate administrative staff to provide broad oversight for VISN Radiology and Nuclear Medicine.

Responsibilities are many and involve all areas of administrative and clinical operation within this clinical domain. While the exact reporting structure of the Clinical Lead, specific methods for communication, field engagement and support may vary, major responsibilities are detailed below. These functions are conceptual in nature and although under the general purview of the Clinical Lead, are typically accomplished on a day-to-day basis by the administrative support representative/HSS, while the Clinical Lead provides overall direction, strategic planning, and interfaces directly with senior VISN and VHACO leadership.

It is therefore critical to the effectiveness of the VISN Diagnostics ICC that appropriate administrative support is provided to Radiology to accomplish these complex tasks, which include daily data monitoring, regular communication with sites, preparation of presentations, planning site visits, monthly call agendas and face to face meetings, performing safety inspections, monitoring compliance and accreditation, organizing equipment and lifecycle planning meetings, preparing management reports, VISN contracting activities, and many other administrative functions that are not expected of the Clinical Lead, who typically has collateral duties as a Service Chief or busy clinical provider. Because the administrative support functions for Radiology are highly specialized and require a detailed knowledge of radiology clinical operation, including scheduling rules, orders management/ADPAC functions, imaging equipment, including HCHT imaging devices and PACS, the administrative staff responsible should have the appropriate clinical background, training and FTEE to carry out these complex and varied functions.

Responsibilities of the Radiology and Nuclear Medicine Clinical Lead and HSS/administrative include but are not limited to the following:

1. Exploring and maintaining VISN level contracts and standardization that improve system-wide delivery of care and efficiency, including:

a. Along with VISN Biomedical Engineering and Capital Asset Manager, HCHT Imaging equipment, lifecycle planning, standardization, procurement and installation for all VISN facilities.

b. Along with VISN Biomedical Engineering and OIT, overseeing contracting, operation, maintenance and standardization of VISN PACS.

c. Along with facilities management and relevant space and construction planners, working to provide state-of-the-art, patient-centered imaging facilities across the VISN.

d. Working with facilities and Community Care representatives to assure appropriate quality and compliance for Community Care Imaging referral services as needed.

2. Directly organizing and coordinating all oversight, strategic planning, data analytics/management and quality improvement activities for Radiology and Nuclear Medicine Services within the VISN;

a. Providing liaison between National Diagnostics ICC and VISN Radiology and Nuclear Medicine Services;

b. Overseeing scheduling and orders management processes for VISN Radiology and Nuclear Medicine;

c. Overseeing and providing guidance to CMO regarding Radiology/NM Credentialing, Privileging, OPPE and provider issues related to quality/standard of care;

d. Communicating and ensuring implementation of all relevant national policy/guidance, including changes to existing guidance, and documenting communication to facilities;

e. Working with facilities to redistribute Radiology/Nuclear Medicine workload through VISN teleradiology and/or NTP when necessary for local radiologist staffing shortages;

f. Sharing and spreading of best practices;

g. Evaluating and responding to adverse clinical events in Radiology and

Nuclear Medicine;

h. Assisting facilities with inspections, accreditation, and regulatory compliance;

i. Overseeing access improvement for Imaging;

j. VISN Radiology and Nuclear Medicine quality oversight and providing guidance for all quality improvement (QI) processes at VISN and facility levels;

k. Staffing oversight, especially as pertaining to access, safety and quality of services;

l. Patient safety improvement, including oversight of image-guided invasive procedures, compliance with Procedural Complexity requirements, and addressing related safety issues;

m. Providing consultation and standardization assistance for fiscal and efficiency matters, regarding budget, mapping and cost;

n. Productivity/efficiency enhancement for radiologists and technologists as applicable;

o. Patient satisfaction trending and improvement;

p. Clinician satisfaction trending and improvement;

q. Workplace satisfaction enhancement (AES, staff turnover rates);

3. Enhancing and facilitating interfacility communication among the Radiology and Nuclear Medicine community through:

a. Monthly VISN Imaging calls

b. Regular site visits to each VISN Radiology/Nuclear Medicine Service with formal findings and recommendations

c. Organizing and facilitating VISN Radiology/Nuclear Medicine face to face meetings (one to two per year as logistically feasible), for policy updates, equipment planning, sharing of best practices, quality improvement and strategic planning.

4. Reporting minutes of Imaging subcommittee to the VISN Diagnostic ICC Committee;

5. Provide subject matter expertise to VISN and VAMC leadership regarding Radiology and Nuclear Medicine as needed;

6. Partner with other VISN-level clinical and administrative services to meet organizational goals;

7. Partner with the corresponding VACO Diagnostic CSL Subcommittee to promote bidirectional communication to achieve organizational goals

3 STANDARD OPERATING PROCEDURES

3.1 ORDERS MANAGEMENT

Last Reviewed/Updated: 6/5/2018

All radiology and nuclear medicine examinations ordered by VA practitioners will be entered electronically in the VistA order entry package as a radiology or nuclear medicine order, whether they are performed in-house or are outsourced. This practice reduces the chance that redundant or conflicting orders will be entered by different providers, facilitates accurate coding and workload capture, and is a prerequisite to report and image storage. Paper orders will only be accepted if VistA is not operational.

Paper orders will be entered in the electronic order entry package, or the radiology package, when VistA operation is restored.

Orders will include the following minimum information:

1. Name of patient, date of birth, and social security number;

2. Name of ordering physician, with contact information;

3. Patient location;

4. Desired study, including laterality if appropriate, and special instructions;

5. Relevant clinical history and reason for study. This information is necessary to ensure the correct exam is performed and the clinical question is answered.

6. Date desired.

3.1.1 Modification of Orders

Facilities must have a policy for technologists and radiologists to modify orders for imaging tests and procedures. Topics to cover in the facility policy should include, but are not limited to, simple changes to orders, such as left or right, which may be made by the technologist. Other topics may include changes to imaging protocols which, if the intent of the provider is obvious and/or clear from their documentation, may be made by the technologist, provided the protocols have been approved by the radiology service and/or medical staff, and provided that these changes are properly documented in the EHR (VHA Handbook 1907.01). In no cases should these changes include addition of contrast without verbal or written radiologist or provider approval. For any other changes, approval is required by the radiologist or referring provider, with appropriate documentation in the electronic health record.

Verbal imaging protocols: TJC requires that facilities have local policies defining who can write and accept orders, as well as procedures for verbal orders and how they are documented in the EHR. In Radiology, this is especially applicable to imaging protocols involving contrast, which require medication reconciliation to be done by the radiologist or other LIP at the time the exam is protocoled. These policies should take into account any applicable local laws and regulations. Additionally, if technologists take verbal protocols from Radiologists or other providers, these protocols should be selected from a menu which is preapproved by the medical staff/Medical Executive Committee (or equivalent) as a standing order or “policy order” set, and any verbal protocols used should be documented in the EHR as per local policy.

3.2 SCHEDULING

Last Reviewed/Updated: 5/13/2018

3.2.1 Future Orders

Providers may enter future orders as much as 390 days in advance for follow-up to include semi-annual, annual, or another clinical reason for which the CID is greater than 90 days from the order entry date. These future orders can be handled one of two ways depending on the Veteran's preference and to ensure the Veteran's exam is completed within 30 days of the CID:

1. Schedule in the clinic or within 7 days of the order entry date using two (2) documented attempts (One call, a letter or My HealtheVet).

a. If the Veteran calls for the appointment, schedule the appointment. If they ask to wait until the date is closer, you can place the order on HOLD using the reason ‘FUTURE APPT’. Radiology will need to run the HOLD list to track Future Orders.

b. If the Veteran does not contact Radiology, then place the order on HOLD using the reason ‘FUTURE APPT’. Do not cancel the order.

c. Note: As long as the CID is entered correctly, these orders will not show up on the Obsolete Order report and will not be considered obsolete until 60 days past the CID.

2. Place the order on HOLD using the reason ‘FUTURE APPT’ and then later, such as 45 days before the patients clinically indicate date, make two (2) attempts to contact the patient.

a. The Veteran contacts Radiology, schedule the appointment.

b. Veteran does not contact Radiology, then you can cancel the order with

‘UNABLE TO CONTACT THE PATIENT’ after two attempts and waiting 14 days after the letter is sent.

For additional information, please see the August 2016 scheduling guidance.

3.2.2 Urgency

The information below is taken directly from the August 12, 2016 guidance titled, Veterans Health Administration (VHA) Outpatient Radiology Scheduling Policy and Interim Guidance (UPDATED) (VAIQ 7722255).

The CID is entered by the ordering provider based on the Veteran's healthcare needs which determine the “Urgency” of the exam. There are three urgencies’ in the radiology package: STAT, ASAP, and ROUTINE.

STAT is defined as an "immediate" exam and should be completed in 24 hours unless otherwise indicated. The sender of a STAT order is required to contact the Radiology Service to notify them that a STAT order has placed, enter “Today” as the CID, and Enter "STAT" in the urgency field of the order.

ASAP is defined as completing the study within 14 days of the CID. For exams ordered as ASAP, which corresponds to the Urgent status in CPRS, the ordering provider is to communicate with the Radiology Service at the time order entry or at patient check out from the ordering provider's clinic is done to ensure an appointment is scheduled in a timely manner to meet patient care needs.

ROUTINE exams should be completed within 30 days of the clinician’s CID.

3.3 UTILIZATION REVIEW AND PROTOCOLLING

Last Reviewed/Updated: 6/5/2018 http://vaww.va.gov/RADIOLOGY/docs/VHA%20Outpatient%20Radiology%20Scheduling%20Policy%20and%20Interim%20Guidance%20Aug%2012,%202016.pdf http://vaww.va.gov/RADIOLOGY/docs/VHA%20Outpatient%20Radiology%20Scheduling%20Policy%20and%20Interim%20Guidance%20Aug%2012,%202016.pdf http://vaww.va.gov/RADIOLOGY/docs/VHA%20Outpatient%20Radiology%20Scheduling%20Policy%20and%20Interim%20Guidance%20Aug%2012,%202016.pdf

Facilities should develop local policies for standard imaging protocols and utilization review. Practice standards should be modeled after the ACR practice standards.

3.3.1 CT Protocols

1. The written or electronic request for a CT examination should provide sufficient information to demonstrate the medical necessity of the examination.

2. The request for the examination should come from a physician or other LIP.

3. CT protocols are to be entered by radiologists or radiology trainees during normal business hours, but otherwise may be entered by other LIPs when radiologists are not present. In the situation when an ED physician, hospitalist or other LIP is routinely selecting the CT protocols, it’s recommended that they are given training on the various available imaging protocols, including contrast issues and contraindications, radiation considerations, appropriateness/clinical indications and limitations of the different protocols, so that they can make an informed choice that is in the best interest of the patient. The basis for requiring LIPs to enter protocols (as opposed to technologists) is to screen for appropriateness, to do medication reconciliation when contrast is used, and select the proper imaging protocol. Therefore, when using contrast, the signed protocol should be either scanned in or alternatively an electronic protocol should be used. In signing the protocol, the supervising LIP is certifying that he/she has reviewed the labs, medications and relevant medical history and is ordering the contrast (which is in the form of a protocol). Note: The imaging order is not a protocol.

Therefore, CT protocols are not to be entered by technologists based solely on the imaging order entered by the referring provider. IV contrast, including screening, risk factors and other information are discussed in a separate section.

However, facility should follow procedures outlined in local IV Contrast Policy.

4. Nationally developed guidelines, such as the ACR’s Appropriateness Criteria, should be used to help choose the most appropriate imaging procedure to prevent unwarranted exposure.

5. The Lead radiologist, lead CT technologist and qualified medical physicist should collaborate to design and review all new or significantly modified protocol settings.

6. The facility should establish radiation dose thresholds during any new protocol design.

7. A periodic review process should be instituted (typically annually) for all protocols to ensure that no changes have been applied that unnecessarily degrade image quality or unreasonably increase radiation dose. At the time of the annual review, protocols should be optimized to reduce dose when possible, comparing with national reference values, and results of the dose optimization process should be reported to the Radiation Safety Committee. This process typically is a collaborative effort, involving a radiologist knowledgeable in dose optimization and CT protocol development, a lead or supervisory CT technologist and a medical physicist.

8. CT protocols should be dose optimized for patients by weight/body habitus

9. Dedicated low dose protocols should be established for select indications, for example:

• Lung nodule follow up

• Lung Cancer Screening exams, if LCS is offered

• Renal stone protocol CT of the abdomen and pelvis

• Noncontrast phases of multiphasic abdominal exams

• Select CTA exams, by optimizing kV

10. Alert values should be set and any doses exceeding alert values should be reported to RSO and/or QI Committee as appropriate

11. Standard protocols should be “locked” in the scanners, so that only key staff have access to change them.

12. Protocols should be standardized across campuses, when facilities have multiple CT scanners in different locations, whenever possible.

13. The CT dose estimate display option should not be disabled and the dose information must be included in the patient’s medical record. This is typically done by automatically transferring the dose page to PACS as a DICOM image in newer systems (which facilitates DICOM-based tracking systems), but may also be dictated into the radiology report, or entered as a note by the technologists, all of which are acceptable.

14. Each imaging facility should have documented policies and procedures for monitoring and evaluating the effective management, safety, and operation of equipment involved in the use of ionizing radiation for therapy, diagnosis and imaging. The quality control program should be designed to minimize patient, personnel, and public radiation risks and to maximize the quality of the diagnostic information or therapeutic benefit.

3.3.2 MRI Protocols

1. MRI protocols are to be entered by radiologists or radiology trainees during normal business hours, but otherwise may be entered by other LIPs when radiologists are not present. In the situation when an ED physician, hospitalist or other LIP is routinely selecting the MRI protocols, it’s recommended that they are given training on the various available imaging protocols, including contrast issues and contraindications, MRI safety considerations, appropriateness/clinical indications and limitations of the different protocols, so that they can make an informed choice that is in the best interest of the patient. The basis for requiring LIPs to enter protocols (as opposed to technologists) is to screen for appropriateness, to do medication reconciliation when contrast is used, and select the proper imaging protocol. Therefore, when using contrast, the signed protocol should be either scanned in or alternatively an electronic protocol should be used. In signing the protocol, the supervising LIP is certifying that he/she has reviewed the labs, medications and relevant medical history and is ordering the contrast (which is in the form of a protocol). Note: The imaging order is not a protocol. Therefore, MRI protocols are not to be entered by technologists based solely on the imaging order entered by the referring provider. IV contrast, including screening, risk factors and other information are discussed in a separate section. However, facility should follow procedures outlined in local IV Contrast Policy.

2. The written or electronic request for an MRI examination should provide sufficient information to demonstrate the medical necessity of the examination and allow for its proper performance and interpretation of the examination.

3. The request for the examination must be originated by a physician or other appropriately licensed health care provider.

4. Images should be labeled with the following: a) patient identification, b) facility identification, c) examination date, and d) image orientation indicated by unambiguous polarity symbols (e.g., R, L, A, P, H, F).

5. Safety guidelines, practices, and policies must be written, enforced, reviewed, and documented at least annually by the supervising physician, in accordance with MRI Safety Directive.

6. A screening program should be implemented to assure appropriate and safe use of MR contrast material and to reduce the risk of nephrogenic systemic.

Gadolinium safety and screening is covered in a separate section of this guide.

7. Appropriate emergency equipment and medications must be immediately available to treat adverse reactions associated with administered medications.

The equipment and medications should be monitored for inventory and drug expiration dates on a regular basis.

3.4 COMMUNICATION OF RESULTS

Last Reviewed/Updated: 7/31/2018

A radiologist is ideally available for consultation to the ordering provider, both before the study is ordered in order to determine the most appropriate procedure, and after the study is performed to discuss the interpretation.

The VHA policy for Communicating Test Results to Ordering Providers and Patients is VHA Directive 1088:

http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=3148.

3.4.1 Results Communication Policies /Medical Center Memoranda (MCM) Each medical center must have a policy for the communication of imaging test results to ordering providers that also includes ensuring clinical surrogates will receive results when the ordering provider cannot be contacted and, in addition, a process for documenting these communications that is clearly auditable. Although the results communication policy should be developed and approved locally, at minimum, the policy should include the following elements:

https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=6430 http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=3148

a. Delineation of basic responsibilities for results communication (both to ordering providers and patients) in accordance with VHA Directive 1088.

b. Definition of critical imaging results for that facility (see “critical imaging results” below), including for patient safety and auditing purposes the maximum acceptable time between interpretation by the “diagnostic provider” (i.e., the interpreting radiologist) and notification to the ordering provider.

c. Description of critical imaging results auditing process necessary to meet The Joint Commission requirements and indicating where audits are reported (e.g., to the Radiology Quality Improvement Committee or equivalent).

d. Guidelines for acceptable methods of communication in different situations (e.g., critical, non-critical but potentially harmful, etc.), including which types of findings require “non-routine” communication, which refers to communication of a test result that may be required in addition to the official report.

e. Cascades of responsibility when communicating Imaging results to ordering providers and/or clinical surrogates, if ordering providers/clinical surrogates are not available. This chain of responsibility may also be followed for any significant abnormal findings, even if not meeting the criteria for critical imaging results.

An example results communication policy is available in the Sample Policies folder on the VHA Imaging Services SharePoint site and can be adapted as needed for local use.

3.4.2 Diagnostic Codes

Radiology exams and procedures must be documented in the medical record as Radiology reports. The VistA Radiology package has support for Radiology diagnostic codes to be appended to Radiology reports. Use of standardized national diagnostic codes is encouraged to minimize variation, facilitate national data analysis, and in some cases, reduce provider “alert fatigue.” The Radiology Service Chief should establish policies/procedures for the use of diagnostic codes and work with the Chief of Staff to ensure that view alerts for all significant abnormal results are set as “mandatory” in CPRS. The threshold for determining “significant” abnormal results, for the purposes of setting view alerts, should be determined locally. Inactive diagnostic codes in the VistA Radiology package must be inactive in voice recognition reporting system.

3.4.3 Method of Imaging Results Communication

The dictated Radiology report is, for the purposes of results communication, considered “routine communication” of imaging results to ordering providers. However, there are certain circumstances where additional communication is necessary to assure expeditious and reliable management of abnormal findings, and consequently, the best possible outcome for the patient. Therefore, in addition to the dictated Radiology report, the following situations may require “non-routine communication” of results to the ordering provider or clinical surrogate [adapted from ACR Practice Parameter for Communication of Diagnostic Imaging Findings, 2014]:

a. Findings that suggest a need for immediate or urgent intervention: for example, critical results as defined by facility policy.

https://vaww.infoshare.va.gov/sites/diagnosticservices/NRP/Mammography/Sample%20Policies/Forms/AllItems.aspx https://vaww.infoshare.va.gov/sites/diagnosticservices/NRP/default.aspx

b. Findings that are significantly discrepant with a preceding or preliminary interpretation of the same examination and where failure to act may adversely affect patient health.

c. Findings that the diagnostic provider reasonably believes may be seriously adverse to the patient’s health and may not require immediate attention but, if not acted on, may worsen over time and possibly result in a major adverse patient outcome. An example of such a significant adverse finding might be an unexpected malignancy.

The following methods of “non-routine communication” are acceptable and may be used [adapted from ACR Practice Parameter for Communication of Diagnostic Imaging Findings, 2014]:

a. Direct communication: Communication by telephone or in person to the ordering provider (or clinical surrogate). This may be accomplished directly by the diagnostic provider or, when appropriate, by the diagnostic provider’s designee.

This communication, including the time and means of communication as well as the name of the ordering provider (or clinical surrogate), must be documented in the patient’s medical record. This is typically documented in the official radiology report but alternatively may be accomplished by a note in the patient’s medical record.

b. Automated results reporting systems, with documentation in the patient’s medical record.

c. Encrypted email, which requires verification of receipt by the ordering provider (or clinical surrogate). This communication, including the time and means of communication as well as the name of the ordering provider (or clinical surrogate), must be documented in the patient’s medical record.

d. CPRS view alerts are a useful adjunct for results communication but are not a substitute for direct communication for some significant findings.

e. Ancillary personnel (e.g., Radiology reading room assistants) who are specifically tasked to assist radiologists in communicating findings and documenting in the patient’s medical record, may be designated to assist radiologists in communication. (Note: FTEE requirement for reading room assistants is variable and should be defined by the facility).

f. In specific cases where reliable systems have been devised for tracking of results (e.g., lung cancer screening programs), a specific provider or coordinator may be designated by the facility to manage results. This may be a substitute for direct communication, and may be an acceptable form of “non-routine communication.”

3.4.4 Critical Imaging Results

“Critical imaging results” or findings that have the potential to be life threatening or cause serious harm and that require an urgent intervention or change in patient management, must be communicated directly to the ordering provider (or clinical surrogate). These results are designated as “critical” based on the specific diagnoses, (see examples below) not based on ordering priority. Direct communication of critical imaging results may be made face-to-face, telephone, or hand-carried report. To verify the accuracy of verbally communicated critical imaging results, a “read-back” confirmation of the essential elements of the result will be requested by the diagnostic provider or their designee. The time and means of such communication, the name of the person contacted, and the person making contact must be documented in the medical record, either in the report or in a separate note. Each facility must develop a system to audit the communication of critical results, the most common being assigning a critical imaging result diagnostic code at the time of dictation, which facilitates querying of critical imaging results and auditing of communication times.

The Joint Commission requires that each facility define its own list of critical imaging results. These critical imaging result findings must be quickly communicated to the ordering provider or surrogate, and a record of the communication of the findings documented in the medical record. Each facility should define its own critical imaging results. The following are a few examples of potential critical imaging results that facilities may use in local policies, but this list is not all-inclusive, and some items may not be appropriate for all facilities:

a. Intracranial hemorrhage or hematoma with significant mass effect

b. Intracranial mass with herniation

c. Unstable cervical spine fracture

d. Tension pneumothorax

e. Acute aortic dissection

f. Pulmonary embolism

g. Free air in abdomen (if no recent surgery or other expected cause)

h. Significantly misplaced tube or line with imminent danger to the patient

i. Testicular/ovarian torsion

[Note: In 2010, the Joint Commission revised their Patient Safety Goals. Although Critical Results remain a requirement, they are to be distinguished from Critical Radiology Tests, which are no longer a specific Radiology requirement. While many facilities may opt not to include Critical Radiology Tests, if individual facilities wish to specify them, reasonable tests might include stroke protocol, non-contrast CT scans of the brain and/or abdominal intraoperative radiographs for possible retained foreign body.]

An important distinction should be made between critical imaging results as defined in local policy, and other significant/potentially harmful imaging results. The purpose of establishing critical imaging results is to ensure that immediately life/limb-threatening conditions are communicated to the ordering provider quickly so that they may be acted upon, and that this timeliness is audited and documented as a performance measure for the facility. For that reason, serious but non-urgent conditions such as potential malignancy without complications, large but stable aneurysms and other diagnoses that are not immediately life or limb-threatening (i.e., within minutes or hours) should generally not be included in a facility’s list of critical imaging results, recognizing that many of these findings are still important and may require phone calls or other non-routine communication.

3.5 MEDICAL RECORD ENTRY AND RETENTION

Last Reviewed/Updated: 5/11/2018

3.5.1 Radiology Report Retention

Reports must be retained according to the provisions of Record Control Schedule 10-1, and the National Archives and Records Administration (NARA). Reports are part of the consolidated patient medical record, and as such must be kept for 75 years after the last episode of care.

3.5.2 Images

1. Images must be retained for the minimum period specified in the Record

Control Schedule (RCS 10-1) regardless of whether images are stored on film or digital media. If the radiology service is informed that a patient has filed a tort claim, the patient’s images should be retained for at least as long as that claim is being adjudicated.

2. Mammograms that have been acquired on film may not be digitized for purposes of interpretation. Mammograms that have been acquired digitally may not be stored using lossy compression, as specified by the Food and Drug Administration.

3. The OSHA asbestos standard, 29 CFR 1910.1001, mandates that hard copy chest x-rays of employees be maintained by the employer for the duration of employment plus 30 years.

3.5.3 Asbestos Standards/Pneumoconiosis Screening

The National Institute for Occupational Safety and Health (NIOSH) has detailed information about screening workers for pneumoconiosis on their web site:

http://www.cdc.gov/niosh/topics/chestradiography/digital-imaging-updates.html)

3.5.4 Releasing/Importing Images and Reports

When transmitting Veteran data to outside providers via electronic media, one must ensure security and privacy of the patient are maintained. Information regarding releasing and importing patient images and/or reports may be found in Health Information Management Brief – “Handling Health Information in Electronic Records” https://vaww.vha.vaco.portal.va.gov/sites/HDI/HIM/vaco_HIM/subsite5/subsite3/Practice %20Briefs/Forms/AllItems.aspx?InitialTabId=Ribbon%2EDocument&VisibilityContext= WSSTabPersistence http://www.cdc.gov/niosh/topics/chestradiography/digital-imaging-updates.html https://vaww.vha.vaco.portal.va.gov/sites/HDI/HIM/vaco_HIM/subsite5/subsite3/Practice%20Briefs/Forms/AllItems.aspx?InitialTabId=Ribbon%2EDocument&VisibilityContext=WSSTabPersistence https://vaww.vha.vaco.portal.va.gov/sites/HDI/HIM/vaco_HIM/subsite5/subsite3/Practice%20Briefs/Forms/AllItems.aspx?InitialTabId=Ribbon%2EDocument&VisibilityContext=WSSTabPersistence https://vaww.vha.vaco.portal.va.gov/sites/HDI/HIM/vaco_HIM/subsite5/subsite3/Practice%20Briefs/Forms/AllItems.aspx?InitialTabId=Ribbon%2EDocument&VisibilityContext=WSSTabPersistence

Additional information about ‘Releasing a Veteran’s Imaging Study’ can be found on the Radiology SharePoint:

https://vaww.infoshare.va.gov/sites/diagnosticservices/NRP/Mammography/Radiology% 20National%20Calls/2017_December_Call/Releasing_Veterans'_Imaging_Studies_by_ CD_DVD_IAP_Dec_2017.pptx

3.5.5 Informed Consent

Informed consent must be appropriately documented in the health record. Treatments and procedures that are low risk and within broadly-accepted standards of medical practice (e.g., routine X-rays) require oral informed consent. Treatments and procedures that are higher risk require signature consent. The requirements related to informed consent are defined in VHA Handbook 1004.01 “Informed Consent for Clinical Treatments and Procedures”.

http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2055

(Note: Technologists are not authorized to obtain informed consent.)

VHA Handbook 1004.01 and VHA Handbook 1004.05, iMedConsent (http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=3064) mandate the use of iMedConsentTM software to document the signature informed consent process, and if iMedConsentTM cannot be used, Department of Veterans Affairs (VA) Form 10- 431a, “Consent for Clinical Treatment or Procedure” must be utilized and retained in the respective Veteran’s electronic medical record.

3.6 JOINT REPORTING AND/OR ARCHIVING OF EXAMS IN THE EHR AND PACS

Last Reviewed/Updated: 8/21/2020

Because of the inherent complexities associated with workflow, the reporting and communication of imaging exams requiring interpretation by multiple providers should be given special consideration by Radiology Services employing these processes. To assure the most reliable and expeditious delivery of care, facilities should develop clear and concise policies and procedures that address joint interpretation and reporting of radiology exams and procedures by multiple providers (which may include radiologists and/or licensed independent practitioners (LIPs) in other clinical specialties).

When applicable, facilities should also develop policies and procedures addressing how other clinical services archive their imaging exams in radiology PACS.

The intent is to establish clarity of responsibility for the exam or procedure, to ensure that all clinically relevant findings are appropriately communicated and reported in the electronic health record (EHR), and to ensure that all exams and orders are appropriately dispositioned. A significant limitation to overcome with any joint reporting scheme is the inability of the VistA radiology package and Cerner EHR to recognize and https://vaww.infoshare.va.gov/sites/diagnosticservices/NRP/Mammography/Radiology%20National%20Calls/2017_December_Call/Releasing_Veterans'_Imaging_Studies_by_CD_DVD_IAP_Dec_2017.pptx https://vaww.infoshare.va.gov/sites/diagnosticservices/NRP/Mammography/Radiology%20National%20Calls/2017_December_Call/Releasing_Veterans'_Imaging_Studies_by_CD_DVD_IAP_Dec_2017.pptx https://vaww.infoshare.va.gov/sites/diagnosticservices/NRP/Mammography/Radiology%20National%20Calls/2017_December_Call/Releasing_Veterans'_Imaging_Studies_by_CD_DVD_IAP_Dec_2017.pptx http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2055 http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=3064 provide for co-equal LIPs (as opposed to attending staff and trainee) collaborating on the same case.

While not possible to cover every potential circumstance, this document addresses the most common situations and provides guidance for appropriate resolution of the exam and report. Major scenarios addressed include:

1. An imaging study registered in the radiology package requires two LIPs for joint interpretation in the radiology package.

2. Two LIPs (typically radiologists) redundantly reporting or overreading the same report.

3. Radiology Service provides technical and professional services for an exam or procedure performed by another clinical service, with reporting both in the radiology package and elsewhere in the EHR.

4. Radiology Service provides technical services only for an exam or procedure performed by another clinical service.

5. Another clinical service stores images in PACS, with no other technical or professional services provided by the Radiology Service.

NOTE: All references to Radiology Services and radiologists includes Nuclear Medicine Services and nuclear medicine physicians.

NOTE: All references to the VistA radiology package and VistA/CPRS includes Cerner Rad-Net and Cerner EHR.

NOTE: All references to PACS includes VistA Imaging (or the Cerner Image Archive).

3.6.1 An Imaging Study Registered in the Radiology Package Requires Two LIPs for Interpretation in the Radiology Package

This may occur in the situation where two clinical specialties each contribute a relevant professional component to be reported in the radiology package. Examples may include:

1. Cardiac imaging studies (e.g., nuclear medicine stress tests or cardiac CT angiograms) co-interpreted by radiology and cardiology in the same report.

2. Radiologists and nuclear medicine physicians co-reading PET/CT.

Systems must be in place to ensure both components of the report are documented and finalized and that both parties are aware of clinically important findings. Local policy (i.e., MCM or Radiology Service SOP approved by medical center leadership) should be developed to assign relative responsibilities and operational procedures for report interpretation.

The optimal methodology in this situation is for the two providers to physically read out together at the same place and time. This has the advantage of promoting interaction and ensures both parties are aware of, and agree to, all findings. Another advantage is that it is relatively easy to administratively track cases to ensure the report has been finalized. It is important that the report contain a statement documenting the names of both reporting providers contributing to the report and indicating their mutual concurrence, as the signature line can only accommodate one primary reporting physician.

Alternatively, one party could report and sign their component and the second party could separately addend their findings to the finalized report. It is important that the report contain statements clearly documenting the names of both reporting providers and their respective contributions to the report. In the event of otherwise unexpected clinically significant findings, the provider who makes the addendum must ensure notification of both the co-reporter and the referring provider, with documentation of the notification in the report addendum or as a note in the EHR. Because this reporting methodology negates routine methods to track report completion, additional measures must be established to audit every case to prevent the possibility of addendum non-completion.

NOTE: See separate NRPO guidance and procedures regarding report addenda.

3.6.2 Two Providers Redundantly Reporting or Overreading the Same Report This situation may occur when two providers are reporting or overreading the same case in the radiology package to establish an adequate case load to maintain proficiency or for purposes of credentialing and privileging. Examples may include:

1. Double-read mammography.

2. Exams or procedures interpreted by a radiologist obtaining new privileges in conjunction with a privileged proctor.

Documentation of the dual reporters should be made appropriate to the circumstances.

Typically, issues arise only if there are significant discrepant findings that must be reconciled. Discussion to reach agreement should occur; if necessary, an independent third reader may be required to form “ground truth” consensus. An alternative (for example, in mammography) is to agree to allow the more conservative interpretation to guide management.

If no preliminary or finalized report has been released or made visible in the EHR, the report may be altered or deleted before final signature verification or report release. If a finalized report requires correction, refer to separate NRPO guidance for Radiology Report Correction for proper policies and procedures. If there is a clinically significant discrepancy from the original finalized report and if the timing and circumstances are such that the discrepancy would realistically alter patient management, the referring provider or responsible surrogate must be notified, with appropriate documentation made in an addendum to the report or as a note in the EHR.

3.6.3 Radiology Service Provides Technical and Professional Services for an Exam or Procedure Performed by Another Clinical Service

This situation may occur when the Radiology Service provides technical services to the performing clinical service provider, however by prior agreement the images are submitted for radiologist interpretation and reporting. In this instance, the radiologist would report into the radiology package whereas the other clinical service would typically place their documentation elsewhere in the EHR. Typical examples may include:

1. Modified barium swallow studies performed by Speech Pathology.

2. Fluoroscopic-guided interventional gastrointestinal or biliary procedures performed by GI service.

3. Intraoperative procedures, e.g., fluoroscopic GU or orthopedic procedures, vascular surgery angiograms, and hybrid operating room cases.

If the radiologist encounters a clinically significant finding which may affect patient management that the provider obtaining the images or performing the procedure may be unaware of, the findings should be communicated using non-routine methods, e.g., phone call, encrypted email, or another direct closed loop process. This is especially important if the radiologist does not have access to the other provider’s findings or report. Appropriate documentation of the notification, including date, time, and person notified) should be made in the report itself (possibly as an addendum, depending on the timing of notification) or as a note in the EHR.

3.6.4 Radiology Service Provides Technical Services Only for an Exam or Procedure performed by Another Clinical Service

This situation may occur when the Radiology Service provides only technical services (e.g., Radiology Service technologist support without a radiologist personally participating in the procedure or formally interpreting the images) for another clinical service. By prior agreement the other clinical service assumes full professional responsibility for the exam or procedure, including image interpretation and results communication, if needed. The exam or procedure documentation by the other clinical service will typically be elsewhere in the EHR, rather than in the radiology package [see next section below if the other clinical service is permitted to report into the radiology package]. Examples may include:

1. Fluoroscopic-guided interventional gastrointestinal or biliary procedures performed by GI service.

2. Ultrasound guidance for thoracentesis or paracentesis performed by medicine service.

3. Fluoroscopic or ultrasound-guided pain management procedures performed by Pain Management Service.

4. Intraoperative procedures, e.g., fluoroscopic GU or orthopedic procedures, vascular surgery angiograms, hybrid OR cases.

A local MCM or Radiology Service SOP approved by medical center leadership should be developed to assign responsibility for interpretation (and manner of documentation in the EHR) to the other clinical service.

Typically, an administrative radiology report would be entered indicating that technical services only were provided and referring to documentation by the other clinical service elsewhere in the EHR for findings or results.