SIIM: Info on chronic conditions missing from clinical history in 40% of cases

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 - Missing puzzle piece

LONG BEACH, CALIF.— While missing information about a patient’s clinical history can hinder a radiologist during interpretation, pertinent chronic conditions are often omitted from the clinical history provided by referring physicians, according to a study presented May 15 at the annual meeting of the Society for Imaging Informatics in Medicine (SIIM).

Moreover, if a condition is not mentioned in the clinical history from a referrer, it’s more likely to be omitted from the radiology report, said Piotr R. Obara, MD, of the University of Chicago, who presented the findings.

Results were based on a retrospective analysis of cases featuring a patient with one of seven conditions considered pertinent at the point of radiological interpretation. These included Crohn’s disease, HIV and lupus. Twenty patients per condition were selected who had a baseline study confirming the condition, and then a follow up study of the same procedure a least 11 months after the baseline.

Looking at the follow up cases, in 40 percent of the clinical histories provided by referrers the pertinent chronic condition was not mentioned. In 62 percent of the cases in which the condition was not mentioned in the provided history, the radiologist also did not mention the condition in the radiology report, explained Obara.

In speculating as to why the referring clinician would neglect to include a relevant chronic condition in a provided history, Obara suggested it may be as simple as the ordering physician not knowing about the condition. A technical hurdle also could be to blame, with the computerized physician order entry system not allowing adequate flexibility to include information about chronic conditions that aren’t on a standard list of options.

Stat cases were more likely to omit a condition, indicating that a time crunch can affect whether a condition is mentioned or not. “Because of their busy schedules, clinicians might delegate some of the order entry duties to non-physicians such as nurses who might not know the patient as well or just might not be aware of how important specific information is to the radiologist,” said Obara.

Natural language processing technology could be leveraged to summarize relevant data sources as a means of compensating for an incomplete clinical history, according to Obara.