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 Link to this message Harry Bardgett  posted on Wednesday, March 23, 2011 - 10:49 am Edit Post Delete Post Print Post
Dear Users,

I am e.R+R lead at Bradford Teaching Hospitals. In our wish to have a Report Acknowledgement System (as set out in the RCR Standards, Feb 2010) and through our discussions with CfH, iSOFT and HSS we have realised there is no HL-7 message standard for a "clinical acknowledgement". There are standards for technical message delivery to an EPR but when a clinician reads a report in the work list of an EPR (SystmOne, EMIS, Lorenzo etc) and ticks the box to take clinical responsibility for that report there is no current way to message back from the EPR to an RMS.

We would like (with CfH help) to make an application to HL-7 to have a Clinical Acknowledgement message standard created which would include;

1. Name of practitioner acknowledging
2. Practitioner ID (GMC No etc)
3. Grade of practitioner
4. Date of acknowledgement
5. Time of acknowledgement
6. Site-terminal ID where acknowledgement performed

This would be sent to the RMS for completion of the reporting cycle. We would like to seek the support of the RCR Imaging Informatics Group in this application to give it extra weight and credence.

Thank you for feedback and I hope you can support this application to HL-7

Harry (Bardgett)
 Link to this message Neelam Dugar  posted on Wednesday, March 23, 2011 - 07:05 pm Edit Post Delete Post Print Post
Hi Harry,

The RCR Results Acknowledgement Standard was largely compiled based on the discussions on this forum. It is a functional & clinical standards document. We did not specify any IT standards in the document.

Most radiologists feel & RCR agrees that the responsibility of the radiology department ENDS when a report is authorised & sent to the referrer. Radiology departments are responsible for providing timely results. For 2ndary care our responsibility ends when we authorise the report & it becomes available on PACS. For critical life-threatening reports that a radiologists feels that needs to be acted upon within 2 hours (leaking aortic aneurysm we may need to pick up the phone and communicate the results--depending on circumstances). Nick Hollings gave a very good presentation at one of the Group Meetings.

Electronic tracking acknowledging & acting upon results is SOLELY the responsibility of referring teams. We feel that the final status for each result is "acknowledged" status--it does not matter which system is used to acknowledge the result--EPR, Ordercomms, RIS, PACS, etc.

"1. Name of practitioner acknowledging
2. Practitioner ID (GMC No etc)
3. Grade of practitioner
4. Date of acknowledgement
5. Time of acknowledgement
6. Site-terminal ID where acknowledgement performed "
This is standard audit trails that should be present in any system that performs results acknowledgement in NHS.

Locally for us at Doncaster--ICE Ordercomms will do the Results Acknowledegment (called "filing"). Anyone looking at the audit trail for that report on ICE will be able to see the person who filed/acknowledged the report, date/time stamp as well. If this information is present in ICE there is no need to duplicate this information on RIS or any other system.

Indigo4 Ordercomms also has a similar process for viewing & acknowledging reports.

Hence, it should not matter how results are acknowledged or what system they are acknowledged on---as long as this DOES happen in every Trust in the interests of patient safety.

We are happy to support you in anyway that helps your Trust deliver a results acknowledgement system.
 Link to this message Margaret Cosens  posted on Thursday, March 24, 2011 - 12:22 am Edit Post Delete Post Print Post
Three points about HL7 and electronic acknowledgement:

First, there's some good news in that HL7 UK and the DH are on the same platform in Manchester next Monday 28 March, with conference in the morning NHS only discussion session in the afternoon. If anyone on this forum can make that date (which, sadly, I can't) it would be excellent to give some input of the ideas, the technical and workflow requirements that have been often identified in this webspace. Link to the details, as distributed by the BCS health informatics group, is:

Second, some of the technical team at CfH have put work into requirements for the next generation of messaging standards - HL7 V4 - for requesting and results reporting, working, I believe, with HL7 UK. The RCR document mentioned above by Harry and Neelam was one of those used to reference clinical requirements for Radiology results reporting; and includes the need for the report to be electronically acknowledged. Two who input into those sessions are speaking at the Group meeting at BIR on Friday; each have used order comms for many years as PACS Manager (Anant) and Consultant Chest Physician (Iain) The latter used electronic acknowledgement for years and will probably refer to the strengths and pitfalls on Friday.

Third, some of the challenges for acknowledgement in a truly electronic workflow - as discussed in earlier threads - are a) to ensure the result is seen by the person or team who are actually caring for the patient, which is not always the person or team who made the request, b) to decide how to deal with the sheer number of 'normal / expected' results ... methods for this have been in place in the paper world for a long time... and c) to find an effective, electronic method of dealing with the few results that need an action to be taken.
 Link to this message Harry Bardgett  posted on Friday, March 25, 2011 - 10:45 am Edit Post Delete Post Print Post
Dear Margaret and Neelam,

Many thanks. The HL7UK-DoH road show has moved to the 25th of May. It would be a good time to request a Clinical Acknowledgement message standard.

I feel Neelam describes a more Secondary Care environment for RAS where there is easy access to the EPR for audit of acknowledgement and escalation policies for unacknowledged reports. Although officially the College and the Informatics SIG feel the responsibility ends once you have clicked verify I think there are many Radiologists who would want to extend their clinical responsibilities further especially out to Primary Care. Certainly in Bradford we would like to know if important or urgent reports have been acknowledged by Primary care and rather than access the Primary Care EPR it would seem logical to have the option to view it in our RIS. Departments who do not want that information can always not receive back clinical acknowledgement messages.

It would be great to know if the RCR Informatics SIG would like to support an application to HL7 or if they feel it is not required or outside of its remit.

Many thanks

 Link to this message Neelam Dugar  posted on Saturday, March 26, 2011 - 09:26 am Edit Post Delete Post Print Post
NPSA Safer Practice Notice 16---RCR standard on results acknowledgement system (compiled from discussions by our group) is based on NPSA SPN 16--which clearly defines responsibilties--for referring consultants vs. radiologists.

"Recommendations for action by referring registered health professionals:
Ensure systems are in place to provide assurance that requested images are performed, and the results of these are viewed, acted upon accordingly and recorded. It is the referring registered health professional's responsibility to ensure this is followed.

Recommendations for action by radiology departments and reporting radiographers and radiologists:
Ensure systems are in place to assure your organisation that radiological imaging reports are accurately and effectively communicated to the responsible health professional. These should include:
i defining and developing a policy for radiological imaging reports which require particularly timely and reliable communication, for example, abnormal, unexpected and/or critical ranges;
ii empowerment to reject inadequately completed requests for studies where appropriate;
iii explicit timeframes for reporting results;
iv regular audits of compliance with the above points."

Our department at Doncaster COMMUNICATES reports
1. paper reports
2. to PACS
3. to PAS
In future we will send to reports to ICE Ordercomms which has a electronic tracking/acknowledgement system.

For Critical/unexpected reports--for inpatients our clerical staff would telephone ward, for outpatients we would ring the responsible consultants secretary & for GPs we fax the report.

We have housekeeping process to ensure that EVERY radiology exam has a report which is communicated on paper, PACs & PAS.

It is commendable if radiologists in Bradford want to share the responsibility of reading & ensuring that reports are acted upon. However, it is unlikely that most NHS departments will be able to take on this extra responsibility, due to pressure of existing workloads.

As a radiologist, I report more than 10,000 exams per year (I am sure that most NHS radiologists have a similar workloads). I ensure that report is clear & provides clear findings & clinical recommendations on further patient management if relevant. However, reading & acting on my recommendations is clearly the responsibility of the referring responsible consultant or GP.

On behalf of the RCR Imaging Informatics Group I am happy to support the development of a technical standard HL7 standard for results acknowledgment. However, the clinical standards for responsibility of reading & acting on reports should remain with referring consultants/GPs as per NPSA SPN 16.
 Link to this message Harry Bardgett  posted on Sunday, March 27, 2011 - 12:03 pm Edit Post Delete Post Print Post
Dear RCR Imaging Informatics SIG,

Many thanks for supporting the application to HL7 UK for a "Clinical Acknowledgement of Result" message standard in HL7.

This is just a message standard, if individual Imaging Departments wish to accept this message to their RIS/RMS systems it is purely up to them. EPR systems now have the choice to use a standard message for their internal acknowledgement of results.

Harry (Bardgett)
 Link to this message Margaret Cosens  posted on Tuesday, March 29, 2011 - 12:10 am Edit Post Delete Post Print Post
Harry, I believe this is an important initiative and hope you will post progress on it to this forum? Whilst it is and should be the responsibility of the referrer to ensure the results are reviewed and acted upon as necessary; having the messaging standard to record it is a natural progression toward an EPR capturing a record of the full care of the patient from request through to result being reviewed (and acted upon where necessary). And the ability for a Radiologist or reporting Radiographer to quickly ascertain whether an unexpected result has been actively reviewed may save some time / phone calls, too.

Those of us who have worked to implement full electronic acknowledgement within EPR (including Rob Etherington and Iain Keeping who spoke at BIR on Friday) can say that having the ability in an acute setting to acknowlege electronically - complete with audit trail and escalation processes for unacknowledged orders - does not of itself beget an effective, fully electronic acknowlegement process. The challenges I mention above are some that need addressing ahead of implementation. It would be good to hear from anyone who has this already in place.

Many Trusts have electronic links to GPs in place for labs, and quite a few now for Clinical correspondence, e-discharge and Radiology reports. My former Trust used MedisecNet. By acessing the patient's record in EPR, MedisecNet link, you could see when the letter or Radiology report had been delivered and when it had been opened/access by the Surgery. I would imagine this is also true in ICE, Indigo, etc? To my tiny, acute Trust -centred mind, that's a pretty good indicator that the report is in the safe hands of the patient's GP surgery, but you still have to initiate a search.

Having an HL7 standard available for Acknowledged status would be a step forward in both settings.
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