QUESTION: I've been hearing a lot about the overuse of diagnostic imaging modalities. How can I order X-rays without placing patients at risk for excessive radiation?
Posted in Clinical Risks on Saturday, November 10, 2018
ANSWER: This can be a tricky issue, but here are a few strategies that can help.
Expect recommendations to be challenged. Payers demand that imaging is clinically justified and patients are concerned about their lifetime radiation exposure. Explain to patients that you cannot palpate abnormalities of the spine, and it’s better to see inside rather than guess. Share that you will only view regions symptomatic or relevant to reduce exposure, and you will only take follow-up X-rays if clinically warranted.
Contact a facility before sending the patient if a patient presents with an overt trauma history or radicular symptoms that may require images other than standard X-rays. The onsite radiologist conducting the imaging may determine that another modality is more appropriate, special views are indicated or the facility is inadequate (e.g., it doesn’t have an open MRI scanner you need for a claustrophobic patient).
Provide essential information. Radiology facilities have a preferred diagnostic study order form or template they will supply to doctors. These forms include information required by the radiologist, such as the reason for referral and the studies requested. The forms may also ask for a brief patient history, symptoms and possible diagnoses. Even knowing a patient’s age can lead to better identification and observation.
Provide other relevant information. Examples: The patient cannot lie flat due to a spinal deformity or the patient suffers from extreme vertigo and cannot stand without assistance/support.
Establish a follow-up system for results not back in the established response time. If a diagnostic test result is outstanding, contact the radiology facility to avoid treatment delays. Practices can build alerts into either an EHR system or a paper-based “tickler” system.
Review all test results before they are filed to help prevent treatment delays. Sometimes abnormal radiology reports will be filed without a doctor’s review only to be discovered later. This is a scenario ripe for malpractice litigation. Make sure no diagnostic reports are filed without the doctor’s signature, date of review and date patient was informed.
Act on any recommendations for additional diagnostic studies or views. If you do not understand or agree with the recommendations, contact the radiologist—most will welcome your questions. If you elect not to follow the recommendations, document your rationale and the discussion with the patient in your records.