Summa Health is a nonprofit health system in Northeast Ohio. The Greater Akron Chamber documents Summa Health as the largest employer in Summit County with more than 7,000 employees. Summa Health provides comprehensive emergency, acute, critical, outpatient and long-term/home care.
The growing use of CT chest imaging has resulted in increased incidental lung nodule findings on imaging studies. These nodules have historically proved problematic for follow-up.
According to the Journal of the American College of Radiology (February 2016), follow-up rates for incidental nodules range from 30-50%.
“Patients seen in the emergency department are particularly vulnerable to being lost to follow-up on their incidental findings, something unrelated to their original emergency visit,” explained Sandy Kohut, lead lung navigator at Summa Health. “Additionally, arranging follow-up care and further diagnostic studies for asymptomatic conditions such as lung nodules presents a challenge to healthcare organizations.”
However, earlier detection means earlier treatment, which means additional treatment options and increased rates of survival.
“To prevent overdiagnosis, the multidisciplinary team established a best practice in dealing with incidental lung nodule findings.”
Sandy Kohut, Summa Health
“As a result, a team at Summa Health launched a multi-pronged quality improvement project to improve identification and appropriate follow-up of incidental lung nodules identified in emergency patients,” Kohut said.
Summa Health turned to health IT vendor Nuance AI for help with this challenge.
“Nuance’s mPower Clinical Analytics solution would provide us with automated data mining and reporting tools to help identify emergency department patients with incidental lung nodules for follow-up,” said Laura Musarra, senior business performance analyst at Summa Health.
“Summa leveraged both Nuance’s PowerScribe 360 reporting platform and Nuance’s mPower Clinical Analytics to enable the multidisciplinary team to improve follow-up around incidental findings, and in doing so, lead to improved care,” she explained.
Specifically, PowerScribe 360 Reporting is a real-time radiology reporting system that helps radiologists generate high-quality reports quickly and efficiently to increase physician satisfaction and improve patient care, said Musarra.
This solution is modular and highly scalable, using voice recognition, radiology-specific templates and efficiency tools to enhance functionality and deliver more accurate and complete reports, she said.
“mPower Clinical Analytics is a radiology-specific natural language processing (NLP)-driven analytics platform,” she added. “It enables users to easily query and analyze large amounts of unstructured or dictated notes and data in radiology reports, saving time and automating laborious data mining processes. It unlocks valuable data and provides insights, making it easier to monitor, understand and improve clinical and operational performance.”
There are many vendors of healthcare analytics technology on the market. Some of these vendors include 3M Health Information Systems, BaseHealth, Berg Analytics, CareEvolution, IBM, Informatica, LexisNexis, MedeAnalytics, Medecision, Oracle, SAS Institute, SCIO Health Analytics, SPH Analytics and VigiLanz.
MEETING THE CHALLENGE
To better manage incidental findings, Summa Health embarked on the following steps.
First, the health system conducted data reviews to identify incidental lung nodule patients.
“The team conducted data reviews of CT and X-ray reports to identify patients with incidental findings who would be candidates for follow-up,” Kohut explained. “From this information, we determined our current baseline and derived an expected monthly volume of lung nodule follow-up patients.”
Second, the health system initiated a referral and follow-up program driven by so-called lung navigators.
“Lung navigators receive the report from the radiology analyst in a timely manner,” Kohut said. “The navigators review records from the ED visit, review radiology reports, and look for prior imaging for comparison. The navigators reach out to the primary care physician and/or patients to arrange follow-up per 2017 Fleischner Society Guidelines.”
“Technology can help you work more efficiently, but it can’t overlook the human element.”
Laura Musarra, Summa Health
The Fleischner Society is an international, multidisciplinary medical society for thoracic radiology, dedicated to the diagnosis and treatment of diseases of the chest. They are the source of widely accepted clinical guidelines related to the management of incidentally identified lung nodules.
At Summa Health, the lung navigators recommend an expedited lung nodule clinic referral for all actionable nodules and an optional lung nodule clinic referral for nodules requiring continued CT surveillance.
Third, the health system leveraged speech recognition-based radiology reporting and clinical analytics solutions to automate identification.
“Advanced technologies can unlock vast amounts of data from radiology reports, leading to improved access to information and insights that can drive initiatives to improve patient outcomes,” Musarra said. “At Summa Health, these technologies were critical to reliably identifying incidental lung nodule findings in CT and X-ray reports for navigation and follow-up care. The team used mPower Clinical Analytics search queries to mine radiology reports created through their Nuance PowerScribe 360 radiology reporting platform.”
Using basic Boolean logic based on keywords like “impression,” “lung,” “nodule,” and “cm” or “mm,” and excluding unrelated anatomical areas that might also be described by the keyword “nodule,” i.e., “thyroid,” the health system defined its initial test search criteria. These easily executed data searches (queries) quickly identified ED patients with potential incidental lung nodules, so that an organized follow-up strategy could be implemented, Musarra explained.
Fourth, the health system expanded a multidisciplinary lung project team to include ED patients.
“Managing follow-ups required resources from several departments,” Kohut said. “A multidisciplinary team for lung screening and incidental nodule patients was already in place, consisting of nurse navigators, data analysts and key physicians, including pulmonologists, radiologists, pathologists, oncologists and cardiothoracic specialists. Their involvement was expanded to include the patients being identified through the ED initiative.”
Once patients with lung nodules are identified in the ED, the lung navigators receive notification from the analyst along with the radiology reports. Actionable lung nodule cases may be reviewed by the multidisciplinary team as needed throughout the diagnostic process and provide recommendations according to nationally accepted guidelines such as the National Comprehensive Cancer Network (NCCN) guidelines.
NCCN is a not-for-profit alliance of 28 leading cancer centers devoted to patient care, research and education, and is dedicated to improving the quality, effectiveness and efficiency of cancer care so that patients can live better lives.
“The navigators are responsible for organizing and acting as a patient liaison and performing all liaison activities, including working with referring physician offices and patients to manage and track follow-up testing and outcomes,” Kohut said.
And fifth, the health system established an organizational best practice.
“To prevent overdiagnosis, the multidisciplinary team established a best practice in dealing with incidental lung nodule findings,” Kohut stated. “They conduct regular review of CT scans of incidental lung nodules. The team carefully weighs additional and potentially risky testing or procedures for conditions that may be benign and could cause harm for conditions that would not lead to morbidity or mortality if they were never detected.”
In the first six months, the quality improvement initiative helped realize a 662% increase in the number of patients identified each month for follow-up – from 8 per month to 61 per month.
“For patients with actionable lung nodules (>8mm), consultations to pulmonologists were expedited by lung navigators, with approval from primary care physicians to lung nodule clinics,” Mussara explained. “The increased number of patients contributed to the opening of a new lung nodule clinic.”
Most important, the multidisciplinary team established a best practice in dealing with incidental findings.
“They conduct regular review of CT scans of incidental lung nodules to prevent the issue of overdiagnosis,” Mussara explained. “The team carefully weighs additional and potentially risky testing or procedures for conditions that may be benign and could cause harm for conditions that would not lead to morbidity or mortality if they were never detected.”
ADVICE FOR OTHERS
“Technology can help you work more efficiently, but it can’t overlook the human element,” Mussara advised. “What problems are you trying to solve? How does this impact workflows? For example, we saw a high number of patients with malignant lung conditions as a need for early intervention. We implemented a multidisciplinary lung navigation team for ED patients, which were key to timely, expedited patient care; consistent nodule coordination, communication and follow-up; and improved physician feedback.”
Once staff knew what problem they were trying to solve and how they were going to solve it, they implemented a reliable technology that would help them save time and work more efficiently, she added.
“We established organizational best practices for managing incidental nodules, in particular, developing the communication mechanisms with referring physicians to educate them about the program and obtain their feedback,” she noted.
Another key element was continuing to refine query/search logic based on how staff knew their radiologists were dictating, and to continue working with radiologists on what keywords to use to optimize results, she concluded.
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