O. Clark West, MD, is a Professor of Radiology, Department of
Radiology, Memorial Hermann Hospital–The University of Texas Medical
School at Houston, Houston, TX.
“Dr. West, would you please take a quick look at the images on this
DVD on a new trauma patient?” asks the PGY-3 trauma surgery resident.
“Could you also give us a final reading on those?”
Over the past 7
years, my thinking on how to manage “outside images” at our trauma
center has completely changed. In 2005, when images on transferred
patients arrived on film, or increasingly on CD, one of our radiology
residents would look at the studies, correlate them with any written
materials — which might consist of a handwritten note or, occasionally, a
final report — and answer any questions the trauma surgery resident
might have. Attending radiologists would occasionally be consulted for
problematic cases; the attending trauma surgeon would also usually be
involved in this consultation.
Documentation of this process,
however, was not uniform. Formal second-opinion reports were
infrequently created, usually only incases of a major discrepancy
between the outside report and our consultation. Most often, the
communication was entirely verbal. Sometimes, the trauma resident would
synthesize the essence of the consultation and record his or her opinion
in the clinical notes. With few exceptions, the consultation was not
documented in the radiology information system.
That system had
one overarching advantage, however — minimizing the amount of time and
effort radiologists spent consulting on outside images. I believed then,
and I do now, that our consultations were useful in identifying the
patient’s injuries and reviewing them with the trauma surgery team.
However, the behavior of our trauma surgeons and other critical-care
colleagues would suggest that the benefit of our verbal consultation was
limited. Examinations were frequently repeated so a final written
report could be issued by the attending radiologist.
there were widely recognized problems with this informal, curbside,
undocumented consultation. Leonard Berlin recommended, “When asked by a
physician for a curbstone consultation, radiologists should, if at all
possible, convert the oral consultation into a formal written report,
even offering to do so as a courtesy and without remuneration.”1
Rich Duszak outlined some requirements to creating a billable,
second-opinion radiology report. These included 1) a written report, 2)
medical necessity at a higher standard that justifies a second report,
and 3) an appropriate -77 modifier.2 Despite these opinions
and knowing we were on thin ice with our informal verbal consultation
model, many radiologists continued to limp along with it.
recent trends, however, have forced me to reconsider our management of
outside images. First, computed tomography (CT) scanning has become the
primary imaging modality for evaluation of the multiply-injured patient.
Increasingly, CT was being repeated after the patient reached our
center to obtain “standardized” images and a formal written report in
the hospital computer system. While it was only mildly distressing to
repeat a few radiographs, repeating full body CT scans was just too
much. At a time when Image Gently and ImageWisely were becoming the topic of conversation, we could not justify continuing to needlessly repeat CT scans.
the images received from referring emergency centers were increasingly
of higher quality. In particular, CT protocols in use atour center were
widely adopted throughout the community, including the use of
thin-section multiplanar reformation (MPR) for face, spine,chest, and
abdominal imaging. Rationalizing that in-house CTs were of higher
quality and contained more information than outside studies,and thus
worth repeating, lost its credibility.
Third, an increasingly
large fraction of transferred patients arrived with a complete imaging
work-up. The practice of obtaining a few radiographs and shipping the
patient out was disappearing. A way to use “outside images” more
effectively was needed. In 2011, after several years of planning, our
practice implemented a web-based mechanism for transferring DICOM images
from community emergency centersto our trauma center. With outside
images arriving directly to our picture archive and communication system
(PACS), how could we continue repeating studies?
Second-opinion report system
response to these pressures, our practice developed a comprehensive
system for issuing second-opinion reports on images received when
patients are transferred to our center.
The key tenets of our program are:
- A physician requesting a second-opinion report must provide relevant patient history, similar to ordering a new examination.
- Medical necessity must be documented.
Valid reasons for soliciting a second opinion include:
- A questionable finding from the initial interpretation where another physician’s expertise is needed.
- A change in diagnosis resulting from a second interpretation of the results of the procedures.
second-opinion report represents a higher level of care (radiologist
expertise). The higher level of care justification is most appropriate
for multitrauma patients transferred for expert care, pediatric patients
transferred for surgical care, and stroke patients transferred for
aggressive stroke intervention.
- An acutely ill or injured
patient arriving at our hospital with images but without complete
radiology reports. (Re)-interpretation of the images is necessary for
- Upon review of outside images and reports, the admitting physician
at our center has questions requiring expert radiologist consultation.
The simultaneous review of all original reports from the community
hospital is necessary for good medical practice. Radiology clerks assist
us in finding original reports when they exist. Second-opinion
consultations should occur physician-to-physician to optimize
information exchange. When outside images do not meet our strict
criteria for second-opinion reporting, the images are uploaded to the
PACS and held for reference.
Implementing this program required a
great deal of cooperation. Radiology clerks were trained to upload CDs
and DVDs and to manage studies received electronically. Radiology
department team leaders were taught how to create orders for each
outside examination and to link these images with the appropriate order
in PACS. This is a time-consuming process requiring technologists who
are not equally versed in all imaging modalities to perform a series of
repetitive but complex operations. Our colleagues in the emergency
center and throughout the hospital assisted us by appropriately
requesting second-opinion reports and in supplying original reports when
Start-up required several months, including a painful
period of several weeks when every incoming study received a
second-opinion report. The situation improved with adoption of the rules
outlined above. Our trauma surgeons, emergency physicians, and
colleagues throughout the hospital seem satisfied with the improved
availability of second-opinion reports. An initial analysis of
reimbursement reveals that second-opinion readings are compensated
almost at the same rate as primary in-house examinations. In practice,
we issue second-opinion reports most frequently on CT and magnetic
resonance imaging (MRI). Most radiography examinations are uploaded for
reference only. When a study must be repeated in our hospital, we
usually use the preceding outside study for reference and do not issue a
While we are pleased with our initial
experience with electronic image transfer and second-opinion reporting,
we are working toward improvements. For example, our current electronic
image transfer system lacks the means to capture and transmit original
reports from the sending hospital. Currently, we rely on paper reports
sent by facsimile, which are then scanned into the PACS. Within a year,
we should have a standardized method of capturing reports as images.
addition, the process of creating orders and linking them with images
is labor-intensive and needs to be automated. Developing an intelligent
interface between our electronic image transfer system and PACS is
needed. Finally, a feedback mechanism is needed so the sending
radiologist can see the content of our second-opinion reports. This
could stimulate the sharing of information and improve the quality of
care at both centers.
You may now be wondering why we would
undertake this much extra work. Very likely you wish to avoid adopting a
similar process in your hospital.
I would submit that we have a
duty to our patients to make maximum use of the imaging evaluation that
they received before being transferred to a tertiary care facility. We
can no longer justify repeating imaging studies for physician
convenience and ease of billing. In CT, the radiation and cost of a
repeated scans are too high. For all imaging examinations, the technical
fees for repeating examinations are high. The relatively modest
professional charges for providing duplicate second-opinion readings are
far less than the cost of repeating entire examinations, particularly
in CT and MRI.
As more hospitals adopt second-opinion reading
programs, their value can be more rigorously assessed to determine if
the time and expense is justified. Such evidence is important in
convincing third-party payers that a streamlined method for reimbursing
second-opinion reporting is warranted.
In the meantime, you may
wish to start planning for electronic image transfer and second-opinion
reading in your practice. It is a trend that is unlikely to go away.
- Berlin, L. Malpractice issues in radiology: Curbstone consultations. AJR. Am J Roentgenol. 2002;178:1353-1359.
- Duszak, R. Another unpaid second opinion. JACR J Am Coll Radiol. 2005;2:793-794.