What Else Is In That Scan? UH Radiologists Capturing and Troubleshooting Unexpected Images

UH Clinical Update | November 2023

A trip to the Emergency Department (ED) today increasingly involves some sort of imaging so the medical team can accurately diagnose the problem at hand. But with more and more imaging in the ED, teams are also finding more and more things on patients’ scans that they weren’t looking for – sometimes life-threatening things. Think a lung nodule that can be seen on a cervical spine x-ray after an injury.

“We're finding things that could be potentially life-altering if not managed properly,” says UH radiologist Jennifer Sommer, DO. “The current approach for handling these findings is commonly inconsistent and relies greatly on the effort of individual clinicians.”

A better way: To boost quality and safety for UH patients in the quest for Zero Harm, Dr. Sommer and her radiology colleagues have launched a more systematic way of managing what they call “actionable incidental findings” on imaging scans. It involves using a standardized process for reporting the findings, notifying the patients and the clinicians involved in the case and monitoring the patient’s outcome over time. The new workflow also allows for simultaneous notification of the ordering clinician, the patient’s primary care provider and a special incidental findings navigator. The navigator “closes the loop” by working with clinicians to notify the patient of the finding and coordinate and document follow-up care.

The incidental findings project at UH started out in EDs at two community hospitals. It’s now spread to all UH community hospitals. The results are impressive: Between July 2021 and October 2021, a total of 10 new cancers were detected that were previously unknown, including three breast cancers, two renal cell carcinomas, two lung cancers, and one each of endometrial, rectal and liver cancer.

Impact of Epic: Dr. Sommer says that with the successful implementation of the Epic electronic health record (EHR) at UH, this success will likely accelerate.

“It will make things easier for the providers,” she says. “They’ll receive the messages in their in- basket with direct links to our radiology reports. If we have a specific recommendation for follow- up, they will be presented with the order for a follow-up imaging exam, and they can just click on it.”

Pros outweigh cons: Of course, not every actionable incidental finding on an imaging scan represents a life-threatening problem.

“We also find a lot of things that don't need anything done,” Dr. Sommer says. “But you don't know that until you follow things out longitudinally. The downside is increased stress for patients when we're following things that we learn in hindsight we don't need to follow, which we need to recognize. But in general, the positives do outweigh the negatives. If we find a cancer and we catch it early and treat it, we can save lives.”

Working toward Zero Harm: Dr. Sommer and her UH radiology colleagues believe they’ve found the best approach. Some health systems limit their efforts to only one or two types of incidental findings or only use the protocol at a couple locations. At UH, we are doing this systemwide, and we include all types of findings.