WhiteCoat

Just Checking

CT BB NoseIn one of the hospitals where I work, when we order certain tests in the computer, we have to write the indications for the test on the order sheet. I suppose this isn’t a bad idea in some cases. For example, if an ultrasound might be better than a CT scan to look for the suspected diagnosis, writing the indication may help to provide the most useful test.

The problem that has popped up recently is that the typewritten indications have now turned into a full scale interrogation by the radiology techs. What symptoms is the patient having? For how long? What is the patient’s medical history? What medications?
Apparently this all has to be written on the order form for some patient safety protocols.

I’m even getting regular calls to ask if I “really want the test” and then ask why I am ordering the test – even though the indication for the test is written on the order.
Just double checking, of course.
It isn’t uncommon for two techs to ask me if I really want a test in some cases.

The director of the radiology department approves of all the questioning. After all, it improves patient safety. I’m not sure how repeated questioning improves patient care and I haven’t been persuaded to change or cancel any of the tests I have ordered, but I am now beginning to see how the pre-authorization process would dissuade some doctors from ordering certain tests. Some doctors just get tired of dealing with the hassles involved in ordering the tests.
I’m not one of those doctors, though.

Initially, I planned to just start typing “yes I really want the test” in the order comments. Then, my better judgment got the best of me. A statement like that probably wouldn’t look too good if the charts were sent to outside hospitals or other third parties.

Although the actions of the techs are frustrating, they are just doing the job assigned to them by their boss. Not really fair to give them a hard time.

How would you address the situation? Is it even worth complaining about? Let me know what you think.

27 Responses to “Just Checking”

  1. mhn says:

    tough situation. I agree – any hard time given to the techs is misplaced and ineffective. I would discuss this issue with the ED medical director, Chief medical officer and/or head of radiology. I would approach this from a patient safety & throughput aspect. The repeated interruptions make caring for other patients less safe and increases length of stay. Do the people who want the increased questioning have any data to suggest that their new technique improves patient safety?

  2. Larry Sheldon says:

    [Not a practitioner of any sort]

    Since the first of the year, whenever a new prescription is sent to Caremark, their (I guess) robot calls from an anonymous 800 number, demand private information (like the magic password to ALL secrets, my birth date) and then demands to know if I want the new prescription sent.

    Which is a good thing I guess–my wife got a script for an antibiotic bomb (4 tabs of something take all at once) that was sent electrically to Walmart (good) and to Caremark (bad).

  3. GrumpyRN says:

    I thought US hospitals did any test requested as long as they could charge for it. I like that sometimes we, as requesters, can be challenged. In UK we sometimes had to write JFDI on requests.

    (JFDI – Just F***ing Do It).

  4. Heliox says:

    Isn’t it partly an insurance thing, too? EKGs for example-a surgeon will write an indication “preop” but unless they can come up with another reason( HTN, arrhythmia, CAD, etc. ) insurance will deny the claim and the patient will be stuck with a 185 dollar bill. Without the EKG, anesthesiology may reject the case.

  5. TH says:

    I primarily work nights. Ordering a Gallbladder Ultrasound at night usually ends up with usually 2, sometimes 3, phone calls from the night rad tech asking ‘does it need to be done tonight?’

    The answer is always ‘yes.’

    Now, they’ve started demanding more and more clinical information. I have standing orders with the ED desk clerk to cut/paste what is completed of my EHR note and put it into the ‘Further clinical information’ box (which is right under ‘Indication’). Fortunately, that box doesn’t have a limit on characters.

    On a related note, now some the Respiratory Therapists have gotten in on the game. One in particular seems to challenge every intubation and ABG. I lost my patience with him after the third episode in two shifts and kicked him out of the ED.

    Don’t get me started on newly graduated paramedics and their ideas about who needs a field IV start and who does not.

  6. DocHodson says:

    Can’t fault the tech’s; they’re just doing what their employer tells them, and they can be fired if they don’t.

    I’d agree with mhn; argue it from an effeciency and throughput standpoint. Things like this are why I fled my academic medical center for community medicine post residency. Granted, our shop isn’t too test-heavy; EG, I order about 1 MRI a month there, and usually find bad things on it.

    Much less negative test results than when I was a resident, though as a young attending, I question if perhaps I should be ordering more.

  7. ThorMD says:

    I take the opposite tactic. I profusely thank them whenever they call me. Now that they know they can’t get a rise out of me, they call me less. “Oh, how can I help you. I really appreciate your concern. Of course I still want the test. Thank you so much for checking etc etc”. And they have zero ammo to complain to my boss.

    I think it’s just a stupid power play “let’s see how angry I can get Dr. WhiteCoat today”. Then they can compare notes about what an a**hole you are.

    Remember when you were a resident, all the stupid nurse calls you would get in the middle of the night. “Doctor, just wanted to let you know his K is 4.5, doctor, just wanted to let you know his IV fell out and I started another one etc”. I also thanked those nurses every time they called (and they stopped calling). The residents who swore at them used to get quadruple the phone calls I did.

  8. DS says:

    I agree with Thor’s take on the situation. It’s a passive-aggressive play by the rad techs (or respiratory, pharmacy, etc.). The more we react to it, the more they do it.

    I suggest that we stop taking their calls, and in the interest of patient safety, insist that they come down to the ED, to talk it over, face to face. When they have to leave the comfort of their darkened cave, I think it will change the frequency of their interruptions of OUR workflow.

  9. TH says:

    “in the interest of patient safety…”

    Yes, I think face-to-face discussions would be perfect for some, if not most, of these calls. I will also invite them to bring the radiologist down to make sure there are no misunderstandings.

  10. PaulB says:

    This is a pet peeve of radiologists who universally believe that ER staff automatically order imaging without even seeing or talking with the patient.

    The second related issue is the rapid increase (perhaps due to triage nurses ordering imaging) of inappropriate or dangerous requests. Diagnosis “9mo fell on carpet at preschool” – order c/t head, c/t facial bones, c/t cervical spine. After inquity “no findings on physical exam or troubling history, want imaging just in case.”

    If imaging was only ordered by EM physicians after a history & physical then there would be little problem. However, with the increase of imaging apparently being ordered reflexively by non-physicians, more questions will be asked. Especially when you start to see “gold standard” imaging confirm a diagnosis, and then something with much less sensitivity/specificity being ordered later simply to “make sure.” Or failure to order contrast when it is critical, or ordering contrast when it can prove disastrous.

    Radiologists are also starting to (and likely will be) held responsible for the amount of radiation patients receive. When you have a young man come in for his 9th CT Renal Stone protocol in 6 months (all negative) we are going to question the order. This behavior will be reinforced when the ED physician states that he had no idea the CT had been ordered, let alone his history.

    Now this may very well be more of a problem in some regions as opposed to others.

    I will put it this way. If pharmacy started to occasionally send down the wrong medicine for patients – including some potentially deadly switches – would you start paying more attention to what was sent down?

    • WhiteCoat says:

      I agree with many of your points.

      Radiologists may have such pet peeves, but often (not always) those peeves are based on absolutely zero firsthand knowledge. If the radiologists have such concerns, then I suggest that they cancel the tests or refuse to read them. Unfortunately, it is politically more effective to interpret the tests and then complain to everyone else how “unnecessary” the test was after a normal result has been documented.

      Please show me one instance in which a radiologist has been “held responsible for the amount of radiation patients receive.” Until then, I call bullshit on that statement.
      On the other hand, I could fill pages of comments on the number of times a clinician has been held responsible for failing to order a radiographic test. Unless radiologists want to take responsibility for missing the diagnosis when the test isn’t ordered, you won’t win this argument.

      Your pharmacy example doesn’t quite hold up, but I get your point. If pharmacy is sending down dangerous drugs, of course we will pay attention. Look at the checks that occur with blood transfusions. However, we don’t call up the pharmacy and ask them whether something labeled as Tylenol on the container is really Tylenol.

      Regarding nurse triage and ordering imaging, I agree that some tests are probably not appropriate. I also have worked in multiple facilities and have never seen anywhere that nurses may order CT scans – at least without a doctor’s approval. The standing orders stem from several societal pressures in medicine: patient satisfaction, quick throughput, and even increased revenue.
      Waiting for a doctor to examine someone who rolled their ankle, argue whether an xray is needed, and then accede to the patient’s wishes ties up the room longer. Failing to get a desired test often (not always) results in lower patient satisfaction. Small numbers of unsatisfied patients have the ability to significantly skew a provider’s score. And like it or not, hospitals (and radiologists) earn more money from performing and interpreting “unnecessary” radiographic tests.

      • PaulB says:

        I won’t disagree with much of what you say. However, it also helps to understand what is going on when the radiologist or the tech receives some of these orders.

        There are two extremes when it comes to providing indications for radiology exams. At one hospital, EVERY CT Head comes with an indication of “r/o stroke.” It really helps to know before the patient shows up if this is a patient with severe neurological defects, or if this is a patient with no symptoms or history who is simply seeking narcotics.

        At the other extreme, is when information is muddled by a poor implementation of an EHR. Several years ago there was a new system at one of the hospitals we cover. Apparently, at triage, nurses were told (by an unknown person) to just click any diagnosis at one particular screen because that data wouldn’t actually appear anywhere. Well, it turned out that was the first line of the information given to radiology. So we started getting orders that would have “reason for visit: hemorrhoids” “exam: c/t head w/o.” Now you must admit that would probably cause you to call for clarification. In other cases there were bugs where the listed complaint was from the last visit to another provider in the system. Or even from some random visit.

        There is also one other critical point – YOU obviously know what you are doing. Unfortunately, that cannot be said for everyone. Even worse, in way too many systems it is difficult to determine which ED physician actually ordered the exam. There are still physicians ordering IVU’s for suspected renal stones.

        So you may very well have a situation when we are getting an order with an indication that makes no sense apparently ordered by a random ED physician.

        The next time they call it might be interesting to ask WHAT has caused them to question the order. Perhaps the EHR is telling the tech that you are ordering an abdominal ultrasound on a patient who according to the record is there for a sprained ankle. Or even worse, it may be spitting out “c/t head w/” for a “r/o stroke.”

        As for radiation exposure, monitoring of radiation exposure from multiple exams is popping up in ABR standards. So it would be foolish to ignore the potential malpractice liability from allowing crazy amount of radiation when there is little benefit. So, yes, if a patient shows up who has had 6 negative c/t renal sone at different hospitals we cover in the last 6 weeks, we will probably call and ask – are you REALLY sure? And I do not think that is a bad thing.

      • WhiteCoat says:

        “At one hospital, EVERY CT Head comes with an indication of “r/o stroke.”

        I would suggest that you look at the EMR. If entering all the extra information takes a few extra minutes every time a head CT is ordered and if the default information for obtaining a head CT noncontrast is “r/o stroke,” then providers are entering the information as a matter of efficiency rather than as a lack of clinical acumen. Diagnosis may also have effect on reimbursement and this also may be what the hospital requests.

        “So we started getting orders that would have “reason for visit: hemorrhoids” “exam: c/t head w/o.” Now you must admit that would probably cause you to call for clarification.”

        Agree. But not on every patient on whom a test is ordered.

        “The next time they call it might be interesting to ask WHAT has caused them to question the order.”

        I did that several times and got the same response. Yes they saw the order. Yes, the indication was clear. They were just checking to be sure that was the test I wanted.

        “As for radiation exposure, monitoring of radiation exposure from multiple exams is popping up in ABR standards.”

        When you find a lawsuit or licensing board action stemming from too much radiation, you let me know. In the meantime,

        “Allowing crazy amount of radiation when there is little benefit. So, yes, if a patient shows up who has had 6 negative c/t renal stone at different hospitals we cover in the last 6 weeks, we will probably call and ask – are you REALLY sure? And I do not think that is a bad thing.”

        Not necessarily a bad thing if the doc doesn’t know about the other CT scans. That’s helpful information.
        But if you’re convinced that there is such little benefit, why don’t *you* cancel the test when you see the order come across the computer?

  11. WhiteCoat says:

    Here’s how I addressed the issue.
    I decided that improving patient safety was a good idea. So I created a sheet that included the patient’s name, MR number, DOB, name of the tech taking the x-ray, settings used on the x-ray machine, number of x-rays taken, and radiologist reading the x-ray. After every x-ray, I’d either meet the tech in the hallway or call down to the radiology department and ask them all the questions. Then, next time I saw the tech, I’d ask them to initial the sheets on the patients whom they took the x-rays.
    For the phone calls, I’d also ask the techs to come to the emergency department so that they could fill out another form I created. That form requested that they certify they had read all of my notes in the order entry for the x-ray before calling me and also asked them to state in writing the reason that my notes prompted further questioning. That way I could improve my communication in subsequent orders, of course.
    Initially, the techs asked why I was taking all of these extra steps and I replied that I liked their idea about double and triple checking things for patient safety, so I thought we should be double and triple checking their activities in the ED to make sure that the right xrays were done on the right patient and tracking the amount of radiation the patients were receiving.
    Within a couple of shifts, there were multiple tech complaints and the director of the radiology department came to visit me and asked what the problem was. I told her the same thing. I just loved her idea about double and triple checking things. I also told her that I was going to present this idea at the next medical staff meeting and ask all the other doctors about what additional information the techs should be filling out to improve safety even further.
    Funny, after that conversation I haven’t had any phone calls questioning my orders. The director of radiology doesn’t speak to me any longer, though.

    • TH says:

      @PaulB: no argument there: there SHOULD be questions asked at that point… but not by the tech. That is a doc-to-doc discussion since the liabilities involved are way above the tech’s paygrade. If the ED doc is ordering the 10th head CT for ‘thunderclap headache’ on the patient and the radiologist is questioning it… then that necessary discussion needs to happen physician-to-physician. And the radiologist had best be able to offer up some reasonable alternatives other than ‘you can’t do that.’ Plus, the argument of ‘Our ultrasound techs are getting overworked’ holds no water (which is one I hear alot). And feel free to put in Nuclear Medicine and Interventional in place of ultrasound: when I’m working a 15 bed ED with 9 boarders, ‘busy’ is relative.

      @WhiteCoat: It isn’t often an ED provider makes a new form and can wield it as a blunt instrument of education. Bravo, sir! Bravo!

  12. Larry Sheldon says:

    And while y’all are having a lot of fun eximining string theory to see if any of the extra dimensions can be used to expand the beauracracy in ever mor creative ways, The poor knob that is paying for all of this in several different ways is wondering if he is actually being allowed to live long, or if it just seems that way.

    Some time ago the humidifier on my CPAP machine stopped working. (I am dependent upon the machine, I don’t like lying down anywhere without it. The winter months here in the flatlands, especially the recent winter months, what with the global warmening and all, are when the humidifier is needed most (alternatives; stop heating the house, wake up every hour with all air passages dried out, don’t sleep).

    Called the provider, got an appointment several days out. Took the machine in, Tech said (as close to a direct quote as I can do from memory): “Oooohhh! That is an OLD one, we don’t issue those anymore, they don’t fail often enough”.

    Much hemming and hawing later, he leaves to “see if he can find one somewhere” (they are (the exact model number) advertized in a number of places for $109 or less on the Internet).

    By and by he comes back and says he thinks he has found one–it will cost #149 and change, payable in advance. But, he says, we will need a prescription (to replace a broken part–really?). And they are the only place that has filled a CPAP machine prescription for me.

    He agrees to call the doctor’s office and collects my credit card info and I and my unrepaired machine come back home.

    Several day’s pass and the nurse at my GP’s shop calls and wants to know what is going on, the new state of the art EMR system has no record of me ever having a machine, ever having a sleep study (I’ve had three), ever being in the pulmonary lab (My next semiannual visit is at the end of April), yada yada yada.

    Several days ago, I get a call from the tech, “Do I still want to order it?” !!! I tell him, Yes, please. He tells me it is going to cost $145 and will put through the charge. And they will send the paper to the insurance companies. Who will probably refuse it, what with the new improved health care your lobbyists designed.

    But the highlight of the saga so far? An hour or so later I get a call from a call center saying they had received the order, DID I WANT THE MACHINE? *()^%!@+)*($@!@!

    It was to be delivered to the shop I deal with today, I have an appointment for tomorrow afternoon at 1600.

    • TH says:

      1st of all – they’re not my lobbyists.

      2nd – you shouldn’t need a prescription for a repair.

      3rd – if you’re paying cash for your CPAP machine, you need to raise hell with that company. Replacement should be easy. If you’re using Medicaid or Medicare or any other insurance… you should still raise hell.

      4th – the ‘state of the art’ EHR runs on GIGO just like every other computer system. If your internist (or his staff) didn’t input that you’ve had sleep studies/CPAP/etc., they’re not going to have that record in the EHR. They’d actually have put pull out the paper chart. Sure, they could’ve scanned the chart in, but then they’re paging through an enormous PDF file. This implies that either they did not update the problem list the last time you went in (assuming they’ve had an EHR for more than a year) OR you haven’t been seen in quite some time.

      Either way, I’m glad there’s some manner of resolution coming to you for your CPAP.

      • Larry Sheldon says:

        Probably not a good time to ask who the AMA and others represent–was probably any un-necessary cheap shot. I’m sorry.

        I have called in every now and again (I probably got the machine at Y2K plus or minus 2) for replacement masks and such–never needed a new ‘script. Drove a big truck for a few years–had a lot of trouble running the humidifier on an inverter–it was replaced without a new ‘script several times. (Seems like they did require a ‘script for a loaner when the main machine power switch wore out.)

        There are things that Have to pay-first and get re-imbursed later–I have mixed feelings about that–wish it was legal to turn paper around in less time than seems to be the case.

        I think it is reasonable to expect the EMR to have summaries of surgeries, and things I have on-going ‘scripts and treatments for. Back in the days that I was designing large data systems we did that as a matter of course. Tested stuff too. (Don’t get me started on the dangerous horrors I’ve run across…..)

        I see a cardiologist, an ophthalmologist, an optometrist, a dermatologist and a dentist every six months, and a GP and a orthopedic surgeon on a less rigid schedule but about the same frequency. Others as the need arise. Most of them ask me if there are changes since the last time, and usually other questions that bring up the CPAP in one way or another. My CDL medical certificate made specific mention of it until I quit renewing it.

        My guess is the GPs nurse and the GP dug it out of the old system but I’ve learned not to ask a lot of questions of those two as to how they got stuff done.

        And just to clarify–my beefs are about the System and the Administration. Not the professional staff. (My cardiologist, dermatologist and GP (and I don’t know how many nurses, etc) have quit in the last lear.

        And I didn’t bring up that with the new wonders of the EMR System, looking only at the professionals butt (cute as some of them are) does not make up for either nobody talking to ME, or the watching how many times Google pops up.

    • WhiteCoat says:

      I’m sorry for what you’re going through, but have to say that your descriptive language made me chuckle several times.
      Hope you get this worked out.

      • Larry Sheldon says:

        New, functional humidifier is now in custody. I will sleep better tonight.

        Thanks for letting me vent–it helps.

        And it helps to remember a conversation I had long ago–context: large-scale data processing systems (my favored term for what we were building–I still don’t know what a Management Information System is).

        I came late to the “team” building a system to “mechanize” the creation of, printing of, and billing for yellow pages telephone directories.

        I was in a group responsible for extracting of data from the data base and preparing reports of all sorts.

        In a meeting with data base folks regarding the difficulty we were having extracting the stuff we were being asked to report, I said (in considerable exasperation): “I wish to h€ll I had been there when the data base was being designed because maybe I could have done something about a design that favors the data base maintainers and does nothing for the people who have to use the data.”

        The room got very quiet.

        Finally, the data base group leader quietly said: “It was not designed for us–it is a nightmare to maintain. It was designed to satisfy requirements your people specified”.

        (I later came to the realization that the problem was in two parts–one part was the Input folks had speced all kinds of stuff that had to stored (but not used by anybody) while omitting linkage data that would have allowed us to compute stiff for the reports.)

        The people left out? The customers and the agents that worked with them.

  13. ThorMD says:

    I just remembered my best tech story ever……the chief of radiology brought his wife in late at night for a swollen leg. I called the tech to come in to do an US. However, the tech gave me crap about coming in and said the patient would have to wait until morning. I, of course, didn’t argue, and went in to tell the chief of radiology that his tech wouldn’t come in. The look on his face was priceless. And the look on the tech’s face when he got there after the chief called him at home was priceless too. Starting the next day, we got 24 hour US.

    Passive aggressive works both ways, lol

  14. Sarah says:

    I see that you have addressed the issue. But as an x-ray tech, any calls I have to make are based on protocols written in the department (by the manager and the Radiologists). While I don’t call to ‘make sure’ this is the test that is needed, I usually have to call to confirm a C-Spine 3 View (standard trauma protocol) vs a C-Spine 5 View (which seems to get ordered all the time, but is never wanted).

    It’s best to bring these things up with the Radiologists and the Imaging Manager. I’m glad to hear you acknowledge its not really the techs.

    And as just a rant, I *hate* that the Radiologists want me to be the inbetween for them and any doctor. They want me to call the doc and explain why we aren’t doing a certain procedure that day or why its no the right study, etc. It should be a doc to doc thing.

    • TH says:

      You’re right: it SHOULD be a doc-to-doc thing. And the radiologists know it. They just don’t want to do it. I’m happy to take a call from a radiologist who says “This is Ms. X’s 5th head CT this year…” unfortuanately, they don’t often offer a substitute, which forces me (the ED doc) to ask, “Well, these are the symptoms. What would you suggest?”

      They’ll want an MRI… which I can’t order from the ED because the hospital doesn’t have one. Neither can I give the patient a disposition without some sort of head imaging. The hospitalist won’t admit them without one (I don’t blame them) and I can’t send them home with the ol’ “I’m pretty sure everything is going to be ok, but if it isn’t, come on back” speech.

      I HAVE suggested that perhaps they would like to come down, examine the patient, and offer up their medical opinion. Funny , they never take me up on it.

  15. Larry Sheldon says:

    The mention here if ad hoc reports reminded me of another favorite war story form a very long time ago when there was a Bell System that had a lot of similarities to your average back-woods Army base.

    I worked in a place whose justification was maintenance and operation of long-haul communications facilities, but whose staff was heavily involved in producing reports–reports whose volume severely taxed our supply of minutia. (Of the day-time staff of about 6 or 8, 3 of us spent most of our time preparing reports.)

    One day or latest newly minted first-level manager decided that his route to fame and glory was to Do Something about all the reports and the man-power they required. (In retrospect, it is clear that he correctly suspected that nobody read most of them, and of those that did, a large part was people whose job it was to insure that the report had been filed.)

    His instructions to us were to continue prepare the reports, but instead of dispatching them, we were to put them in an “IN” box dedicated to them.

    Each day he would update a spread-sheet (Form SN-475–a pad of 11″ X 17″ sheets with a lot of little rectangles printed on it).

    If he got called about a report, he retrieved it, updated his spread-sheet, and forwarded the report.

    Depending on a number of variables he would eventually tell us either to transmit a report when complete, or to stop preparing it.

  16. Brent Davidson, MD says:

    For the CT of the head presented with this article, I would submit for the test, R/O metallic FB in the left nose.

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