Np consistently missing fx....what to do

[chudat]

I'm a part time moonlighting rads that read from home for a group.

There is an female NP/PA that consistently misses fx on overnight plain films. I mean she misses EVERYTHING. Triquetral fx, subtle OCDs, sure, but she misses everything.

I get it. Its overnight, its busy, rads are slow to out reports out. But thisbis getting outrageous.

What do you guys suggest.

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[EthylMethylMan]

Sounds like a very real patient safety issue. I don't think this is a situation where directly talking to the person will be helpful. Putting aside the professional friction it would cause, it also probably wouldn't result in any meaningful change. I would talk about it with your medical director. Something definitely needs to be done, and I would imagine your director and the ED director could figure out the best way to manage things per your hospital's policies. Sounds like midlevels shouldn't have autonomy she needs further education.

 

[GonnaBeADoc2222]

What's the matter with you?

Be collaborative.

Give her on the job paid training.

She's part of the team.

-----------

Seriously though, you'd think for all the time these Noctors spend in front of a computer screen during their online DNP, they would look at an image or two.

 

[RustedFox]

So, this NP is working in the ER and entering prelim reads that miss everything?

 

[emergentmd]

OP is confusing to me. He is a radiologist and have ER NP/PA reads that are bad? If so, not your problem.

 

[WilcoWorld]

I'm a part time moonlighting rads that read from home for a group.

There is an female NP/PA that consistently misses fx on overnight plain films. I mean she misses EVERYTHING. Triquetral fx, subtle OCDs, sure, but she misses everything.

I get it. Its overnight, its busy, rads are slow to out reports out. But thisbis getting outrageous.

What do you guys suggest.

I also need clarification - is this NP/PS working in the ED or for your Rads group?

If they're working for the ED, then it appears that they need to wait for Rads reads before discharging a patient. If that's not acceptable to this ED...then they need to find a different job.

 

[chudat]

So, this NP is working in the ER and entering prelim reads that miss everything?

Shes a NP in the ED. The location of the hospital is very rural (like carcosa rural from true detectives), has hard time attracting providers of any kind. This particular hospital ED is staffed with ~75% NPs at all times.

It's an issue because I always have to call the ED the following morning to relay misses that she did on a prelim read. Plus the pt suffers as well.

 

[Vandalia]

General advice: Use the correct language. As mentioned, it is a "patient safety issue." Those are the magic words.

It is always "a patient safety issue." Even if it is not a patient safety issue.

If you decide to take formal action (and that depends on a lot of factors internal to your own group) it is not "The NP is screwing up and she has no business looking at imaging." Even though that is most certainly the case. It is "This provider presents a patient safety issue."

The other key phrase is "the bottom line." If you are able to make it "a patient safety issue that is costing us (them) money", then that is like a Royal Flush.

Yeah, it is BS. But in healthcare whoever is able to master the language first in a dispute wins.

 

[cyanide12345678]

Shes a NP in the ED. The location of the hospital is very rural (like carcosa rural from true detectives), has hard time attracting providers of any kind. This particular hospital ED is staffed with ~75% NPs at all times.

It's an issue because I always have to call the ED the following morning to relay misses that she did on a prelim read. Plus the pt suffers as well.

I hated reading my own films without radiology backup in one site where i worked. Hated pediatric xrays especially. If there was ever any doubt i went ahead and splinted. Have your medical director talk to her medical director. If this person isn’t certain, he/she should just splint and treat it like a fracture.

 

[Janders]

(1) Friendly place where people know each other? Speak to director. Consider liberal splinting. Encourage self-education with peer-review and collaborative review of the patterns of misses with formal education.
(2) Hard ball option. Patient safety issue. Concern directly to hospital / HCQ.

Frankly they should just spring for the price of VRADS or whomever to read the plain films overnight if this provider is so weak but irreplaceable. It costs a little money but gonna save it in the long run…

 

[voxveritatisetlucis]

Write your congressman. I’m sure they’ll do something to limit autonomy expansion

 

[Dr Mantis Toboggan]

I hated reading my own films without radiology backup in one site where i worked. Hated pediatric xrays especially. If there was ever any doubt i went ahead and splinted. Have your medical director talk to her medical director. If this person isn’t certain, he/she should just splint and treat it like a fracture.

I just send any plain films I’m iffy on to VRAD (who reads the CTs and ultrasounds). I’m sure it costs the radiologists $ to do that but they are snug in their beds so I don’t really care.

 

[PikminOC]

It's better for the ER physician to read it themselves rather than have this np do it.

 

[RustedFox]

It's better for the ER physician to read it themselves rather than have this np do it.

You might have missed this:

Shes a NP in the ED. The location of the hospital is very rural (like carcosa rural from true detectives), has hard time attracting providers of any kind. This particular hospital ED is staffed with ~75% NPs at all times.

It's an issue because I always have to call the ED the following morning to relay misses that she did on a prelim read. Plus the pt suffers as well.

 

[Rekt]

Find out how to contact the ED director. She needs to be fired.

Just crazy how we got to this point. I worked with some LLPs in residency for our fast track shifts, but they only staffed very low acuity stuff.

Now out in the real world I have to work with some who pick up regular patients. They're all terrible. It's actually how scary how incompetent LLPs are.

Just hope you don't get sick because you're going to get killed by one of these fools.

 

[EctopicFetus]

What's the matter with you?

Be collaborative.

Give her on the job paid training.

She's part of the team.

-----------

Seriously though, you'd think for all the time these Noctors spend in front of a computer screen during their online DNP, they would look at an image or two.

Looking at images isnt the same as someone teaching you what those images mean. The eyes do not see what the mind does not know.

 

[Birdstrike]

“…consistently misses fx on overnight plain films. I mean she misses EVERYTHING.”

When a person is unable to perform their job safely, there is only one thing to do.

It shouldn’t be controversial.

 

[turkeyjerky]

This sounds like a problem. Midlevels shouldn’t be acting on their own radiology reads. Either you guys need to read overnight, use a telerads service, or have these treated functionally as outpatient images where the patient Is told to come back in the morning for their results.

That said, come to think of it, having worked at a few places where we were responsible for reading plain films overnight, I’ve never actually seen a system where we get notified of the official read and/or a discrepancy, absent the case getting referred for peer review or something. There probably should be some sort of a nonjudgmental, non-QA based system for this.

 

[thegenius]

I'm a part time moonlighting rads that read from home for a group.

There is an female NP/PA that consistently misses fx on overnight plain films. I mean she misses EVERYTHING. Triquetral fx, subtle OCDs, sure, but she misses everything.

I get it. Its overnight, its busy, rads are slow to out reports out. But thisbis getting outrageous.

What do you guys suggest.

Send a memo to the ER group's chief. There isn't much more you can do. Make sure you provide specific MRNs for all the fractures missed too. No point complaining if you can't prove which ones are missed.

 

[thegenius]

This sounds like a problem. Midlevels shouldn’t be acting on their own radiology reads. Either you guys need to read overnight, use a telerads service, or have these treated functionally as outpatient images where the patient Is told to come back in the morning for their results.

That said, come to think of it, having worked at a few places where we were responsible for reading plain films overnight, I’ve never actually seen a system where we get notified of the official read and/or a discrepancy, absent the case getting referred for peer review or something. There probably should be some sort of a nonjudgmental, non-QA based system for this.

I actually think no non-radiology physician should be reading their own imaging and acting on it. What's the point then of having board-certified radiologists and the 4 years they spend reading 10,000 xrays, 5,000 CTs, 5,000, US, and 2,000 MRIs. They train for a reason.

I know it's all about the money, I'm just surprised that this hasn't come back and hurt hospital systems more that I think it would.

Liability is basically all on the supervising ER doc for that NP. Sad.

 

[WilcoWorld]

I actually think no non-radiology physician should be reading their own imaging and acting on it. What's the point then of having board-certified radiologists and the 4 years they spend reading 10,000 xrays, 5,000 CTs, 5,000, US, and 2,000 MRIs. They train for a reason.

I know it's all about the money, I'm just surprised that this hasn't come back and hurt hospital systems more that I think it would.

Liability is basically all on the supervising ER doc for that NP. Sad.

Non-rads docs can and should act on POSITIVE findings (I can start the anticoagulation when I see the segmental PE on the CTA or place the NGT on the SBO), but I agree that what looks negative to me really just means there's nothing big enough for me to catch. So I should wait for the rads read before discharging what looks like a negative CTA to me.

 

[CoolDoc1729]

I actually think no non-radiology physician should be reading their own imaging and acting on it. What's the point then of having board-certified radiologists and the 4 years they spend reading 10,000 xrays, 5,000 CTs, 5,000, US, and 2,000 MRIs. They train for a reason.

I know it's all about the money, I'm just surprised that this hasn't come back and hurt hospital systems more that I think it would.

Liability is basically all on the supervising ER doc for that NP. Sad.

We are “discouraged” from sending to telerad because someone (I think the rads group) has to pay for it. Depending on the situation if I’m not sure I either send it (peds) or CT it (old people hips, tibial plateaus etc)

 

[Cognovi]

We are “discouraged” from sending to telerad because someone (I think the rads group) has to pay for it. Depending on the situation if I’m not sure I either send it (peds) or CT it (old people hips, tibial plateaus etc)

Seems like unnecessary CTs cost the system/patients more and the hospital should spring for the telerad service for plain films.

 

[Arcan57]

Seems like unnecessary CTs cost the system/patients more and the hospital should spring for the telerad service for plain films.

But that unnecessary CT is also generating additional revenue for the hospital, which will more than offset the cost of a telerad read. C.R.E.A.M.

 

[RustedFox]

But that unnecessary CT is also generating additional revenue for the hospital, which will more than offset the cost of a telerad read. C.R.E.A.M.

C.R.E.A.M.
Maaaaan, you just brought me waaay back.

 

[RustedFox]

“…consistently misses fx on overnight plain films. I mean she misses EVERYTHING.”

When a person is unable to perform their job safely, there is only one thing to do.

It shouldn’t be controversial.

Imagine if you did that (or something correspondingly similar)?

What would they do to you?

There's your answer.

 

[chudat]

Imagine if you did that (or something correspondingly similar)?

What would they do to you?

There's your answer.

Well the kicker is that she'll put in Epic 'negative per my wet read, no onsite radiology currently, radiology will over read next day, and if there is a discordance, will call pt back'.

I think this somewhat absolves her liability.

 

[thegenius]

Non-rads docs can and should act on POSITIVE findings (I can start the anticoagulation when I see the segmental PE on the CTA or place the NGT on the SBO), but I agree that what looks negative to me really just means there's nothing big enough for me to catch. So I should wait for the rads read before discharging what looks like a negative CTA to me.

I guess what I'm trying to get at is, if you act on your imaging, and there is a bad outcome, then you and only you should be f'ed.
Of course everybody ought to agree to this premise.

I'm trying to think back as to why I wrote my original comment. I used to work at an ER where XRs weren't read overnight, but all other forms CTs, MRIs, US, etc were read. That irked me. Why should I be responsible to read just my own xrays? Its as if the assumption was "xrays are easy to read, you don't really need to have a radiologist on 24/7." I think xrays are hard to read...especially chest xrays. Rads are always pointing out "streaky pneumonia" when I don't see it, and I find it difficult to read chest xrays from patients with complicated thoracic histories (e.g. CABG with pulmonary fibrosis), and I can never pick up pulm nodules either.

 

[thegenius]

We are “discouraged” from sending to telerad because someone (I think the rads group) has to pay for it. Depending on the situation if I’m not sure I either send it (peds) or CT it (old people hips, tibial plateaus etc)

It's paid for in the morning though. Do overnight telerads charge more for an xray read than daytime hours?

 

[Janders]

It's paid for in the morning though. Do overnight telerads charge more for an xray read than daytime hours?

The way many of the VRADS contracts work is that the hospital / radiology group pays them a flat fee for each study, by study type.

So they might get $30 for reading a plain film at 0200.

Vrads does NOT chase the patient for the bill, engage w/ insurance, etc. They are getting their money from the rads group.

Then, in the morning, the rads group places a formal read, and bills out the patient for said formal read. This may generate between $0 and $100, lets say, depending on the patient’s insurance and all. Plus the rads group needs to cover the overhead of coding, billing, etc etc.

So the $30 is coming out of their potential profit / income stream.

For CT they don’t have a leg to stand on as far as delaying reads until AM, and my impression is the difference between what they pay for a Vrads wet read and eventually get for a formal AM read is usually still enough to get them some cash for the formal read and keep their system churning.

But X-RAY has been allowed to be a double standard, where the ER doc is “good enough” to act on their own reads for 12+ hours, but oddly NOT good enough to bill for a formal read. As well, the income on X-ray is low enough and the VRADS fee high enough that if you start sending 12hr of your ER X-ray out to Vrads, it ends up costing the rads group a good chunk of change they would rather not lose.

So, solutions, to give patients appropriate levels of care—>
(1) My favorite is a new system whereas non-radiologists get to take 50% of the fee for after hours plain films they interpret, and rads gets 50% in the AM for the over-read. I think this is actually appropriate, would generate some revenue for ED, ICU, Hospitalists, but still appreciate and reward a board certified radiologist doing the fine tooth comb work in the morning.
(2) 24/7/365 reads by a real radiologist, be it virtual or local, for all imaging modalities because patients deserve it.
(3) Fine, keep doing what we are doing, but if the ER doc or Hospitalist wants to send 10-20% of their plain films to VRADS because they are complicated, weird, concerning… then yeah rads needs to eat that cost.

 

[WilcoWorld]

But X-RAY has been allowed to be a double standard, where the ER doc is “good enough” to act on their own reads for 12+ hours, but oddly NOT good enough to bill for a formal read.

We talk about uncompensated work - this sounds even worse: uncompensated liability.

 

[Brigade4Radiant]

What would the director say to the NP? Hey since you work nights you have to read X-rays X-rays compared to the day NPs?

Are they billing for the X-ray reads?

 

[RoyBasch]

Well the kicker is that she'll put in Epic 'negative per my wet read, no onsite radiology currently, radiology will over read next day, and if there is a discordance, will call pt back'.

I think this somewhat absolves her liability.

Obviously in a better world the MLP gets the reads right every time. But technically what they are doing is acceptable. You (the radiologist) are being paid to over read the X-ray. It is reasonable to contact the patient regarding the finding 12 hours later. If the finding requires management (say a fracture rather than a nodule) you can notify the ER and If they need to place a splint or something they can call the patient back or decide what they want to do.

You are effectively “supervising” the mid level in this capacity. Welcome to the same vull**** we are all dealing with.

I think a patient going home with a missed non displaced fracture and being un-splinted for one day is not going to drastically effect their outcome. This is not a patient safety issue. People come to the ER days after injuries all the time (“it’s just not getting better doc”) and don’t get splinted until then.

Sure ideally the MLP makes the dx and manages correctly on the first pass and having to call people back is annoying. If you feel this individual miss way more than their colleagues creating additional hassles and frustration for patients then you can refer it to their ER medical director for more education on plain films, but I doubt they will do much.

 

[Mount Asclepius]

I think physicians need to take ownership of interpreting their own imaging. I interpret and act on all of my x-rays at night that then aren’t overread by Radiology until the morning. I also frequently act upon CT imaging without a read. Usually this is when there are positive findings, but rarely sometimes also including an outpatient discharge when appears negative to me, low suspicion, and a read from our overnight, non-local radiology service is taking too long. For example, a negative renal stone study.

A Radiologist once told me, you have to touch the patient. You have the benefit of the exam and knowing where they hurt. Don’t underestimate that. We joke about Radiology using the term ‘correlate clinically,’ but it is so important and true.

Radiologists are the masters of the broad field of radiology. No other specialty does it generally better. However, surgical sub-specialists are occasionally better looking at imaging of their narrow niche than Radiology. I think it’s because they can correlate clinically, spend a lot of time looking at imaging, and take ownership. They are still occasionally wrong. They also value Radiologists’ input.

This gets me to my main point and the point of this thread. LLPs don’t take ownership of practicing medicine. They don’t practice medicine. They follow algorithms. They are similar to beginning medical students. They report information, but don’t use clinical reasoning. Physicians on the other hand practice medicine by using clinical reasoning, interpret studies, make decisions and take ownership. I interpret my own labs, EKGs and bedside US. I also interpret all of my own imaging. Years of putting in the effort has made me more self-sufficient and better with imaging. That doesn’t mean I don’t extremely value Radiologist’s expertise and input. I know what I don’t know. That’s why I’m a physician - ownership and respect for my physician colleagues that know what I don’t.

 

[Janders]

I’m with you, I consider myself a very functional emergency radiologist and I act on a lot of my own interpretations instead of waiting hours for a formal read (I mean CT and US AND X-ray). I think its a very helpful skill set for an emergency provider (Yes PA/NP included) to have… more than a basic understanding of non-con head CT. I FREQUENTLY over-read Vrads CTs and call them to discuss the issues; of course I have the benefit of exam but a few of them are also… just poor, compared to my local rads that work day/evening. {To be clear, most are good and some are really awesome and excellent}

However, I think the same “meh” attitude that lets an unsupervised NP “read” plain films with no training overnight allows radiologists to get full compensation for reading these stat ER films 12-18hr later. Both are subjectation of high quality care to the almighty dollar and the desire of many people not to work rural / nights.

 

[Cognovi]

The way many of the VRADS contracts work is that the hospital / radiology group pays them a flat fee for each study, by study type.

So they might get $30 for reading a plain film at 0200.

Vrads does NOT chase the patient for the bill, engage w/ insurance, etc. They are getting their money from the rads group.

Then, in the morning, the rads group places a formal read, and bills out the patient for said formal read. This may generate between $0 and $100, lets say, depending on the patient’s insurance and all. Plus the rads group needs to cover the overhead of coding, billing, etc etc.

So the $30 is coming out of their potential profit / income stream.

For CT they don’t have a leg to stand on as far as delaying reads until AM, and my impression is the difference between what they pay for a Vrads wet read and eventually get for a formal AM read is usually still enough to get them some cash for the formal read and keep their system churning.

But X-RAY has been allowed to be a double standard, where the ER doc is “good enough” to act on their own reads for 12+ hours, but oddly NOT good enough to bill for a formal read. As well, the income on X-ray is low enough and the VRADS fee high enough that if you start sending 12hr of your ER X-ray out to Vrads, it ends up costing the rads group a good chunk of change they would rather not lose.

So, solutions, to give patients appropriate levels of care—>
(1) My favorite is a new system whereas non-radiologists get to take 50% of the fee for after hours plain films they interpret, and rads gets 50% in the AM for the over-read. I think this is actually appropriate, would generate some revenue for ED, ICU, Hospitalists, but still appreciate and reward a board certified radiologist doing the fine tooth comb work in the morning.
(2) 24/7/365 reads by a real radiologist, be it virtual or local, for all imaging modalities because patients deserve it.
(3) Fine, keep doing what we are doing, but if the ER doc or Hospitalist wants to send 10-20% of their plain films to VRADS because they are complicated, weird, concerning… then yeah rads needs to eat that cost.

Everything you said is right except the price. Prelimming telerads groups pay on the order of $25-30 per wRVU so a chest xray would pay like $4.50. Medicare's reimbursement for the professional fee for a 1 view chest xray is $9.00. You are skimming chump change off of peanuts. Plain films are a money loser in general and any system where more than one professional has to get paid for reading it or overreading it will lose even more money.

 

[Janders]

Everything you said is right except the price. Prelimming telerads groups pay on the order of $25-30 per wRVU so a chest xray would pay like $4.50. Medicare's reimbursement for the professional fee for a 1 view chest xray is $9.00. You are skimming chump change off of peanuts. Plain films are a money loser in general and any system where more than one professional has to get paid for reading it or overreading it will lose even more money.

So I’ve only held one tele-rads contract in my hand, and it was a decade ago, and it was a flat $20 for any X-ray no matter the type.

I’ve been told the going rate is usually $12-25. I clearly have no idea what Medicare or typical commercial payers pay for chest X-ray interpretation, because while I perform that service all the time, I don’t get to bill for it . {except when bundled for critical care}

But yeah, its really a small potato’s argument when it comes to slapping the wrists of bedside providers asking for tele interpretations of plain films overnight.. sending every single one may end up mildly pricey, but sending occasional films seems completely reasonably to me, considering the general cost of this business…

 

[maxxor]

So I’ve only held one tele-rads contract in my hand, and it was a decade ago, and it was a flat $20 for any X-ray no matter the type.

I’ve been told the going rate is usually $12-25. I clearly have no idea what Medicare or typical commercial payers pay for chest X-ray interpretation, because while I perform that service all the time, I don’t get to bill for it . {except when bundled for critical care}

But yeah, its really a small potato’s argument when it comes to slapping the wrists of bedside providers asking for tele interpretations of plain films overnight.. sending every single one may end up mildly pricey, but sending occasional films seems completely reasonably to me, considering the general cost of this business…

I went to a vRad dinner recently. I know what they pay the telerads. It's $21.25 per "work unit" which is not quite equal to an wRVU.

X-rays are 0.3 work units. The conversion makes that $6.75. Profee for X-rays have them in the 0.2 to 0.3 wRVU range. CMS pays around $33 an RVU. You can expect what is paid to vRad is higher than what the telerad gets.

If vrad is reading much X-ray, the rads group loses money overreading on average yet assumes all that liability.

 

[lucid_leprechaun]

I think physicians need to take ownership of interpreting their own imaging. I interpret and act on all of my x-rays at night that then aren’t overread by Radiology until the morning. I also frequently act upon CT imaging without a read. Usually this is when there are positive findings, but rarely sometimes also including an outpatient discharge when appears negative to me, low suspicion, and a read from our overnight, non-local radiology service is taking too long. For example, a negative renal stone study.

A Radiologist once told me, you have to touch the patient. You have the benefit of the exam and knowing where they hurt. Don’t underestimate that. We joke about Radiology using the term ‘correlate clinically,’ but it is so important and true.

Radiologists are the masters of the broad field of radiology. No other specialty does it generally better. However, surgical sub-specialists are occasionally better looking at imaging of their narrow niche than Radiology. I think it’s because they can correlate clinically, spend a lot of time looking at imaging, and take ownership. They are still occasionally wrong. They also value Radiologists’ input.

This gets me to my main point and the point of this thread. LLPs don’t take ownership of practicing medicine. They don’t practice medicine. They follow algorithms. They are similar to beginning medical students. They report information, but don’t use clinical reasoning. Physicians on the other hand practice medicine by using clinical reasoning, interpret studies, make decisions and take ownership. I interpret my own labs, EKGs and bedside US. I also interpret all of my own imaging. Years of putting in the effort has made me more self-sufficient and better with imaging. That doesn’t mean I don’t extremely value Radiologist’s expertise and input. I know what I don’t know. That’s why I’m a physician - ownership and respect for my physician colleagues that know what I don’t.

Same here. At sites with teleradiology overnight you are often the one interpreting your own studies. They are so slow and unreliable that it may or may not be helpful. Often our rads read studies very differently in the morning. The benefit to seeing the patient is that I know what I’m looking for

 

[Mount Asclepius]

It's helpful to hear reimbursement numbers for x-ray imaging. We previously fought and took over full billing of EKGs from Cardiology, which was worth doing financially. We've also considered whether or not we should try to fight for taking over the billing of plain films, especially at night since we are acting solely upon our reads. I think there is more hesitancy given the liability of missing things like pulmonary nodules. Sounds like the reimbursement amount may not be worth the liability.