Comparison of Two Methods to Transmit Clinical History Information From Referring Providers to Radiologists

Purpose

At many institutions, clerical personnel manually enter clinical histories into radiology information systems during the process of scheduling examinations. For outpatients, radiologists use this information as their primary source of clinical histories. The purpose of this study was to determine the discrepancy rate between these manually recorded clinical histories and paper request slips, thereby assessing the accuracy of the clinical information used by radiologists at the time of interpretation.

Materials and Methods

A total of 129 imaging request slips for CT scans were randomly selected from 7 days in February and March 2007. The clinical history on each request slip was compared with the clinical history manually entered into the radiology information system. Discrepancies between paper request slips and the electronic information available to radiologists were placed into 4 categories: 1) no discrepancy, 2) electronic or paper history incomplete, 3) disagreement between electronic and paper information, and 4) other. Incomplete or discrepant histories were further subcategorized on the basis of whether they were clinically significant.

Results

Thirty-eight percent of studies (49 of 129) had no discrepancies between the paper request slips and the manually entered electronic information. The remaining 62% of studies (80 of 129) had incomplete or discrepant clinical histories. Forty-nine percent of studies (63 of 129) had incomplete electronic or paper information. Greater than half of those incomplete histories (36 of 63) were clinically significant. Ten percent of cases (13 of 129) showed frank disagreements between paper and electronic information. Sixty-nine percent of these (9 of 13) were clinically significant. Three percent of studies (4 of 129) showed other discrepancies whose clinical significance could not be categorized.

Conclusion

The manual entry of clinical information introduces a high rate of discrepancies, most of which are clinically significant. These discrepancies highlight the need for better communication between referring providers and radiologists.

Key Words: Quality improvement, informatics, clinical history