This following is a guest post by Dr. Sanket Shah, a Resident Physician in Diagnostic Radiology.

Imaging is an integral part of a patients care.  Radiology is a key diagnostic tool for many diseases while also playing an important role in monitoring treatment and predicting outcome.  Despite the rapid technological advancement in diagnostic imaging, access to this valuable tool often falls through the cracks related to poor imaging referral management.   When choosing a specialist or procedure (including imaging centers), patients rely heavily on their doctor to make the referral that is in the patient’s best interest as outlined in this survey carried out by the Center for Studying Health System Change.  However, it seems that more can be done at the point of care to improve this process.


Often, patients go to see their primary care doctor in the ambulatory setting with an ailment, for which an imaging test is ordered.  For example, a family member recently fell during the Chicago Marathon due to the large crowds at the beginning of the race and injured his elbow.  A day after the race he went to see his primary care doctor.  When I asked him what his doctor said about his elbow, he told me he received a prescription for an elbow X-ray.   As a resident physician in radiology, I was excited to review his radiograph with him only to be disappointed to find out he had not yet gotten his x-ray (almost 2 weeks later).  On top of that, it took him about an hour to find his prescription (see below), which was buried in other important household paperwork, when I asked to see it.

Imagining Referral










The puzzled look on his face when asked where he was going to get the elbow x-ray taken only made my frustrations with the process grow even more.  I spent a few minutes that night looking on the health organization’s website his doctor is affiliated with, where there is a list of preferred in-network imaging centers.  He was essentially expected to set up his own appointment and bring his paper referral with him to the appointment in order for the appointment to be accepted.  As his elbow was still visibly swollen 2 weeks later, I urged him to get the X-ray taken as soon as possible. If he indeed has a fracture (which I suspect he may), the process has already delayed his care.


Beyond the point of care, there are also gaps in physician communication which often cause a delay in patients care.   I can share a recent example which involved a patient getting an X-ray for a sports related injury.  The x-ray demonstrated a fracture in a location which also indicated ligament damage, which was correctly reported by the radiologist.  The ordering physician was late to follow up on the imaging results probably assuming the radiologist or patient would inform him of any abnormality requiring follow-up.  The patient assumed his doctor would have notified him if anything was wrong, and the radiologist assumed the ordering physician would have followed up with the final report or the patient.  This ultimately resulted in delayed care for the patient which rendered him outside of the time window necessary to successfully repair the torn ligament.  Who is at fault?  Is it the individuals or the process? Many providers often do request imaging reports be faxed to their offices once the radiology report becomes available, which often do not go through for many various reasons including a high volume environment.  As a result, imaging findings that are deemed “non-urgent” often fall by the wayside.  With the tools available today, such a process gap should be avoidable and studies have showed that using a referral tool within an EMR can improve physician communication.


Although many larger healthcare organizations are implementing such tools to improve requests for imaging, lab tests, and specialist referrals in the era of accountable care and meaningful use, many smaller organizations and stand alone doctors’ offices still lag behind the curve.  One big hurdle in the system today seems to be the lack of interoperability between large EMR vendors which often limits a physician’s ability to exchange patient information as stated in this recent New York Times article.


As imaging plays a pivotal role in a patients care, it is important for both providers and imaging centers to develop better methods to manage their patients imaging referrals.   If providers were capable of processing an imaging request at the point of care before a patient leaves the primary care doctors office, it can make an immediate impact on a patients care, as it makes them much more likely to follow through with their appointment.   This would also create a healthier relationship and improve communication between imaging specialists and their referring physicians, which is right in line with the American College of Radiology Imaging 3.0 Campaign.   With the patient’s best interests in mind, there is much room for improvement in increasing speed to schedule (in-turn decreasing turn-around time), driving patients to centers in-network, while also improving an imaging centers referral capture rate.  It’s time to utilize technologies that make it easier for patients to get the care they need and for doctors to share information and communicate with each other better to enhance patient care.