The manual entry of clinical information into a RIS can result in a high rate of discrepancies, many of which are clinically significant, according to a study published in this month's Journal of the American College of Radiology.

Rajan Agarwal, MD and colleagues from the department of radiology at the University of Pennsylvania Health System in Philadelphia, randomly selected 129 imaging request slips for CT scans from seven days in February and March 2007. The authors compared the clinical history on each request slip with the clinical history manually entered into the radiology information system.

Discrepancies between the paper request slips and the information electronically available to radiologists were put into four categories—no discrepancy, electronic or paper history incomplete, disagreement between the two sources and other. The discrepancies were considered to be clinically significant if they provided additional information on stage of disease, localization of disease, type of symptoms or disease of if they asked specific clinical questions of radiologists.

According to the authors, of the 129 imaging requests studied, 38 percent had no discrepancies between the paper request slips and the information manually entered into the radiology information system. The remaining 62 percent had discrepancies.

Of the 80 requests with discrepancies, the researchers found that 63 involved the incomplete recording of information, 17 indicated a disagreement between the two sources and four were categorized as "other."

An example of a disagreement (with significant clinical implications) between the paper and electronic sources was a paper request slip that included the term “panc mass” in the patient’s history. This information was entered into the RIS as a “[p]ancreatic cyst.” An example of an incomplete history was a reference to “kidney stones” in one patient’s electronic history, while the paper history referenced “no history provided” for the same patient.

The authors suggested that discrepancies probably occurred when clerical staff members were used as intermediaries to pass the clinical histories from the referring physicians to radiologists. A subsequent decision to scan imaging requests into the RIS allowed for improved communication and a direct handoff of information between referring clinicians and radiologist.

The researchers acknowledged the study was limited in several ways. For example, because the reasons for exams are often not well documented, there was no way to determine which clinical history was correct when the discrepancies occurred. Also, the authors could not assess whether the discrepancies were caused by data entry errors or verbal miscommunications.

Agarwal and colleagues concluded that a reliance on manual entry of clinical information into a RIS can result in a high rate of clinically significant discrepancies, which highlights the need for a better system of communication between referring providers and radiologists.