Integrating digital systems: commitment and collaboration

One year ago, the radiology department at Ball Memorial Hospital, a 350-bed facility in Muncie, IN, was completely film-based. The need to support a new all-digital, 35-room emergency department (ED) hastened the facility's transition to a digital environment. Today, with the exception of mammography, the hospital's imaging services are now digital. To develop and implement the project, the hospital formed an internal implementation team. An independent consultant was also hired to evaluate the impact of these new technologies and to provide an estimated cost payback. After research, site visits, and vendor demonstrations, the hospital selected a single vendor for its picture archiving and communication system (PACS), digital radiography (DR), computed radiography (CR), and overall project management. The DR system was installed in the ED to provide digital image capture for a full range of trauma exams. The ED also initially began utilizing a Web-based PACS distribution originally implemented for after-hours teleradiology. The majority of the hospital's imaging studies are captured with 2 multi-cassette CR systems that serve 7 exam rooms in the radiology department. The hospital also installed remote operations panels to expedite entry of patient and exam information. Technologists readily embraced both CR and DR systems. The Web distribution system now transmits images to hospital-based computers and to 150 remote referring physicians. The PACS platform automatically e-mails key images and radiology reports to referring physicians. Authorized physicians can also request reports and images on an as-needed basis. The PACS vendor had previously performed multiple integrations with the radiology information system (RIS) vendor; the integration of PACS and RIS was extremely smooth. One of the critical components of a successful conversion is experienced, dedicated management. The hospital retained professional project management services to facilitate implementation and to ensure adequate training for all users.     

Construction of a quality assurance system for images in general radiography in a filmless environment: construction of an accurate and swift workflow

When medical records went digital at our hospital, we also went filmless. In the general radiography department, we were forced to change the workflow, so we created a new one. We introduced a system of quality assurance for images between consoles and PACS. As our original improvement, we added to the system a function to automatically narrow down patient images and a function to automatically sort images. We divided quality assurance for images into 1st and 2nd quality assurance and defined and managed it. In addition, we measured the time for each process of the workflow with and without film use. We compared 10 cases of chest and abdomen radiographs with 10 cases of bone radiographs. As a result, by using this system of quality assurance for images, we were able to cut three minutes from each examination, leading to quicker work.     

A tale of two CRs: hospital conducts side-by-side test

While we elected to install a digital radiography system in the busiest exam room in emergency room (ER) suite at our 535-bed hospital, we selected computed radiography as the primary platform for digital capture throughout the facility because of its flexibility, productivity and cost-effectiveness. We now use CR systems to handle six exam rooms and portable exams conducted by the radiology department, as well as imaging studies conducted in two ER exam rooms. Before committing to a CR vendor, we conducted an eight-week, side-by-side pilot study with two vendors' systems. One CR system was located in the emergency room and the other unit was located in the main radiology department. Our staff received education and training from both vendors. I led an evaluation team that included representatives from the radiology group, the information services (IS) department, biomedical engineering, staff physicians, ER physicians, pulmonologists and orthopedic specialists. Our team met to design the trial and develop a list of factors that technologists would use to evaluate the two systems. The team met after installation and again after the trial was complete to provide verbal input on each vendor for each category and to review feedback from the technologists' survey. Categories included image quality, interactions with each vendor's sales and service staff, workflow, time studies, durability of cassettes and plates, entry of John Doe patients for ER, and other factors. After the trial, we chose a system by unanimous vote. We learned a lot about CR technology throughout this process. Overall we are extremely satisfied with the platform we selected and with this method of evaluating the two systems prior to making this important decision.     

Performance improvement using methodology: case study

The department of radiology at St. Luke's Regional Medical Center in Sioux City, IA implemented meaningful workflow changes for reducing patient wait times and, at the same time, improved customer and employee satisfaction scores. Lean methodology and the 7 Deadly Wastes, along with small group interaction, was used to evaluate and change the process of a patient waiting for an exam in the radiology department. The most important key to the success of a performance improvement project is the involvement of staff.     

PACS/RIS系统在放射科工作流程优化中的作用

目的:探讨应用医学影像存档与通信系统(picture archiving and communication system,PACS)在医院放射科工作流程优化中的作用。方法:将放射科数字成像设备纳入PACS系统,将传统放射科工作流程与应用PACS后工作流程比较。结果:应用PACS工作流程后减少工作步骤,缩短报告发出时间,降低错误率。结论:应用PACS后明显提高了放射科的工作效率,方便了医疗、教学、科研和会诊,提高了医院的社会效益和经济效益。     

Underreporting of vertebral fractures on routine chest radiography

OBJECTIVE: Osteoporosis is underdiagnosed and therefore undertreated. We determined the potential usefulness of chest radiography for detecting clinically important vertebral fractures by performing semiquantitative reviews and quantitative digital morphometry on 100 routine chest radiographs taken in the emergency department and comparing the yield of these independent reviews with official radiology reports. MATERIALS AND METHODS: One hundred randomly selected chest radiographs of patients 60 years or older who presented to the emergency department of a tertiary care hospital were evaluated. Radiographs were selected without knowledge of the presenting complaint and were independently reviewed by two board-certified radiologists and a radiology resident. A validated semiquantitative method was used to assess lateral chest radiographs for vertebral fracture. In addition, quantitative digital morphometry was undertaken. A clinically important vertebral fracture was defined as one that was at least moderate to severe (loss of height >or=> 25%). RESULTS: Mean age of the population was 75 years, 47% were women, and 46% were admitted to the hospital. According to the reference radiologist, prevalence of moderate to severe vertebral fractures was 22%. Simple agreement was 87-88% among reviewers; kappa values were moderate (0.56-0.58). The greatest agreement was between the reference standard radiologist and quantitative digital morphometry (89% agreement; kappa = 0.67). Only 55% (12/22) of vertebral fractures we identified were mentioned in the official radiology reports. CONCLUSION: Chest radiography has potential as a screening tool for revealing previously undiagnosed vertebral fractures, although in this study only half of moderate to severe fractures that we identified were mentioned in official reports.     

PACS系统的应用体会

目的：介绍我院影像医学存档与通讯系统（ＰＡＣＳ）应用的经验。材料与方法：将所有Ｂ超、ＣＴ、Ｘ线机和一台ＩＢＭ服务器、四台奔腾Ⅱ档次的工作站及惠普光盘塔连接成医学数字影像传输（ＤＩＣＯＭ）网络;ＤＩＣＯＭ服务器与各种图像浏览终端羞以太网络;通过ＨＵＢ连接成ＰＡＣＳ系统。结果：将常规放射图像的模拟信号通过数字转换器转换为数字信号后,与ＣＴ等数字成像系统的数字信号一并输入光盘塔,并进行诊断。将数字图像和诊断报告一起舆到医院各个图像浏览终端,使其可通过ＷＥＢ界面系统及咨询平台进行查询。ＰＡＣＳ投入使用２年来,效果良好。结论：ＰＡＣＳ的应用明显提高了放射科及相关科室的工作效率,方便了工作、教学、科研和会诊。     

From shared data to sharing workflow: Merging PACS and teleradiology

Due to a host of technological, interface, operational and workflow limitations, teleradiology and PACS/RIS were historically developed as separate systems serving different purposes. PACS/RIS handled local radiology storage and workflow management while teleradiology addressed remote access to images. Today advanced PACS/RIS support complete site radiology workflow for attending physicians, whether on-site or remote. In parallel, teleradiology has emerged into a service of providing remote, off-hours, coverage for emergency radiology and to a lesser extent subspecialty reading to subscribing sites and radiology groups.When attending radiologists use teleradiology for remote access to a site, they may share all relevant patient data and participate in the site's workflow like their on-site peers. The operation gets cumbersome and time consuming when these radiologists serve multi-sites, each requiring a different remote access, or when the sites do not employ the same PACS/RIS/Reporting Systems and do not share the same ownership. The least efficient operation is of teleradiology companies engaged in reading for multiple facilities. As these services typically employ non-local radiologists, they are allowed to share some of the available patient data necessary to provide an emergency report but, by enlarge, they do not share the workflow of the sites they serve.Radiology stakeholders usually prefer to have their own radiologists perform all radiology tasks including interpretation of off-hour examinations. It is possible with current technology to create a system that combines the benefits of local radiology services to multiple sites with the advantages offered by adding subspecialty and off-hours emergency services through teleradiology. Such a system increases efficiency for the radiology groups by enabling all users, regardless of location, to work “local” and fully participate in the workflow of every site. We refer to such a system as SuperPACS.     

CR/DR systems: what each technology offers today; what is expected for the future

Computed radiography (CR) is considered by some to be the work-horse for digital image capture of general radiography exams because it is affordable, offers excellent image quality and exposure latitude and utilizes existing x-ray systems. CR systems deliver digital imaging to general radiology departments and lower-volume areas that can include hospital floors and outpatient imaging centers. Digital radiography (DR) technology is more expensive, but some believe it earns its keep with significant productivity gains and the capacity for higher image quality or lower dose. DR systems are especially appropriate for emergency room settings and high-volume areas in general radiology departments, orthopedic clinics, imaging centers and other facilities. Facilities with growing patient volumes and limited space often choose to install DR systems in one or 2 exam rooms to double the productivity of those rooms, while one or more CR systems serve the remaining rooms or remote areas. Patients benefit from both faster image capture (it takes less time for each imaging exam) and hospitals achieve a digital distribution process that speeds delivery of radiology reports to referring physicians and a more efficient imaging workflow that can lead to increased revenues.     

A comparison of film-screen, CR and DR: a community hospital time-motion study

The purpose of this study was to compare technologist efficiency for conventional radiography, computed radiography (CR) and direct radiography (DR) for two types of general x-ray examinations. The study was performed at St. Joseph's Health Centre, in Toronto, Canada. The study spanned eight calendar months. Two views of the chest and three views of the ankle were chosen as representative examinations for analysis. Patient examination times were recorded on the radiology information system for both types of studies for conventional radiography, CR and DR. There was a significant difference in average time of examination for all three types of imaging formats for chest studies and between conventional radiography and CR or DR for ankle radiographs. There was no significant difference between examination times for ankle studies when CR and DR were compared. The median time of examination of the chest was 18 minutes, eight minutes and six minutes for conventional radiography, CR and DR respectively. The median time of examination for ankle radiographs were 22 minutes, seven minutes and five minutes for conventional radiography, CR and DR respectively. Technologists efficiency is significantly improved with the implementation of a DR system and CR system when compared to conventional radiography. DR may not deliver significant improvements in efficiencies for certain types of examinations.     

Using STAT properly

The misuse of the term STAT has long been a problem in many hospitals. Instead of being the universal word for "immediate," it has become a convenient phrase used, in some cases, to get what the physician wants now. Although the principles of this article may be applied to many modalities in the healthcare field, this article deals solely with portable chest x-rays performed at the University of Minnesota Medical Center, Fairview in Minneapolis. The diagnostic radiology department performed a 2-week analysis of orders in August 2004. The results showed that 74% of all portable chest x-rays were ordered as STAT. The manager, along with a staff radiologist, then created a list of clinical reasons that were appropriate for STAT, ASAP, or Routine orders. Then, there was a 2-week period of time delegated for education, during which the list was brought to the nurse managers of several patient care areas as well as some chief residents at the university's medical school. These individuals then shared the list with their staff. A second analysis conducted in November 2004 showed that an 11% decrease had been achieved. Given that 20,000 portable chest x-rays are performed at the medical center annually, the figure represents a 2,200 reduction in STAT portables per year. With the success of this endeavor, the radiology department piloted a second program to further decrease the number of STAT orders. Since the radiology department was using computed radiography (CR) and a picture archiving and communication system (PACS), research began to unearth the response times. The idea was to advertise to physicians how fast they could get their images, using the theory that if the times were quick enough, perhaps there would less of a tendency to order STATs. The results showed that a STAT order could be completed and viewable on PACS in an average of 17 minutes, and an ASAP in 28 minutes. A poster advertising these response times was generated and distributed to the nurse managers and residents to post in the inpatient units. The poster was well received. A two-week survey conducted in March 2005 showed that STATs now accounted for 54% of the portable chest x-rays. With this two-pronged approach, the radiology department was able to decrease the number of portable chest X-rays by 20%. Another 2-week survey conducted in May 2005 showed that number of portable chest x-rays ordered as STAT declined further to 52%.     

A time-motion study of digital radiography at implementation

With increasing budgetary restraints on the health system, it is apparent that the main contribution that radiology departments can make to significant cost reduction in hospitals is to decrease the length of time between requesting an X-ray examination and receiving the report (and images). Digital radiography (DR) was introduced into the Radiology Department at the Royal Adelaide Hospital as a pilot project to research the cost-benefits and efficiency of the system, and to determine future directions for planning a digital department. The business plan developed prior to implementation of this pilot project predicted a saving of one bed-day per inpatient when a fully digital department with a picture archiving and communication system (PACS) is installed. This initial study comparing DR and conventional radiography (convR) provides baseline data and shows encouraging results for more rapid transmission of reports to clinicians.     

Digital radiography of the chest: state of the art

Digital image acquisition possesses a number of advantages over conventional systems in radiographic examination of the chest, the most important of which is its greater dynamic range. In addition, one digital images are acquired, they can be processed by computer in ways that cannot be rivalled by conventional analog techniques. Finally, digital images can be stored, retrieved and transmitted to local or remote sites. Here the status of the different digital systems employed in chest radiology and commonly used image processing techniques are reviewed. Also discussed are the current clinical applications of integrating digital chest radiography with a picture archiving and communication system (PACS) along with the difficulties typically encountered. Studies with a variety of digital techniques have been carried out on several fronts. Computer radiography based on photostimulabe phosphor (CR) has replaced screen-film imaging in certain applications (i.e. bedside imaging). However, CR has limitations, namely its poor X-ray utilisation efficiency at high X-ray tube voltages and sensitivity to scatter; therefore, it is not ideal for all applications. Recently, a dedicated digital chest unit with excellent X-ray utilisation efficiency at high X-ray tube potentials has been introduced. On the basis during the past decade, recommendations are made regarding the most desirable equipment specifications for dedicated and bedside digital chest radiography.     

A new approach to RIS/DR interconnection.

The article focuses on a new, standards-based approach for linking modalities to a radiology information system (RIS) in the radiology department. Computers have been used in radiology for quite some time-for the complex processing of algorithms used by CT and MR, for example. The advent of computed radiography (CR) and direct radiography (DR) has helped bring x-ray film into the world of computers. DR uses a technology similar to that in digital cameras to convert the intensity and location of the diagnostic image into digital form. Many radiology departments now store images on disks and read from computer monitors in a reading room. With its high-volume radiology department, the Cleveland Clinic Foundation (CCF) has been a long-time user of one particular RIS system. As the department moved to DR implementation, it required a means to automatically include patient demographic information with the image at the time of study acquisition, so this information would be associated with the image throughout its history. Using an approach developed by several companies in connection with CCF, technologists now use only two interfaces on one computer screen. Further, a technologist can close the study from the DR unit, allowing more time for patient care. The collaborative effort between CCF and the companies involved has resulted in an exciting standards-based approach to linking its RIS and DR systems.     

Impact of the Closure of a Large,Urban Safety-Net Hospital on a Neighboring Academic Center: A Philadelphia Case Study

ObjectivesWe examined how the closure of 496-bed Hahnemann University Hospital (HUH), a level I trauma and stroke center and safety-net hospital in Philadelphia, Pennsylvania, impacted the emergency department (ED) and radiology workflow in our neighboring hospital (Thomas Jefferson University Hospital) located <1 mile away.MethodsOn June 30, 2019, HUH announced its imminent closure and began diverting trauma patients, with its ED officially closing in mid-August. Trends of our ED and radiology workflow were analyzed using QlikView analytics software for 3 months before and after the closure. Data were compared to workflow from the same time period in 2018.ResultsThe average monthly number of patients presenting to our ED after the closure increased 20.2% with a corresponding 16% increase in ED imaging studies, primarily in radiographs (+16%) and CT (+20%). Radiology orders by advanced practice providers increased 74%. Turnaround time from imaging order placed to final diagnostic radiology report did not change substantially after the closure.ConclusionWorkflow in our ED and radiology department was significantly impacted by the closure of HUH. This study provides insight into how our practice patterns changed and compensated after the closure of a neighboring, large, urban safety-net hospital; it is important for radiologists to be aware of citywide practice patterns to adapt to acute change.     

数字X线摄影系统中低剂量应用的探讨

目的 通过数字X线摄影系统（DR）在胸部摄影检查中的应用评价DR的低剂量的优越性。方法 利用CDRAD 2.0低对比细节体模评价计算机X线摄影（CR）和DR的影像质量和表面空气吸收剂量（ESD）关系,分别利用两个系统（DR使用ESD约为CR的1/3）得到成人胸部30幅影像。由6位影像科医生来评价以上两者的影像系统对于肩胛骨内侧边缘等胸部结构的清晰程度。结果 CR影像和减少ESD的DR影像在影像诊断质量上差异没有统计学意义（P＞0.05）。结论 DR的较好的分辨率和低噪声特性,以及高DQE有助于减少患者接受的辐射剂量,而不影响诊断质量。     

Enterprise-wide PACS: beyond radiology, an architecture to manage all medical images

RATIONALE AND OBJECTIVES: Picture archiving and communication systems (PACS) have the vocation to manage all medical images acquired within the hospital. To address the various situations encountered in the imaging specialties, the traditional architecture used for the radiology department has to evolve. MATERIALS AND METHODS: We present our preliminarily results toward an enterprise-wide PACS intended to support all kind of image production in medicine, from biomolecular images to whole-body pictures. Our solution is based on an existing radiologic PACS system from which images are distributed through an electronic patient record to all care facilities. This platform is enriched with a flexible integration framework supporting digital image communication in medicine (DICOM) and DICOM-XML formats. In addition, a generic workflow engine highly customizable is used to drive work processes. RESULTS: Echocardiology; hematology; ear, nose, and throat; and dermatology, including wounds, follow-up is the first implemented extensions outside of radiology. CONCLUSION: We also propose a global strategy for further developments based on three possible architectures for an enterprise-wide PACS.     

Acceptance of PACS utilizing a PACS QI Program

This article describes the quality improvement program that Mercy Hospital (Alegent Health System) initiated after it implemented a picture archiving and communication system (PACS) in November 2003. The radiology department encountered numerous PACS-related issues that directly affected the quality and workflow of patient care. In order to get a better understanding of the situation, the department developed a quality improvement plan for its PACS program. The first step was to dedicate a resource--in this case, a radiology information technology (RIT) support specialist--who would serve as a PACS subject matter expert while dealing with day-to-day PACS-related issues--specifically, errors. The error data were collected and categorized for consistency using statistical process control (SPC) tools. The information gathered was then traced back to the team members responsible for the errors and used as a training tool to further educate them. As a result of this program, the average error rate was reduced from 12% to 4% because the radiology team developed a better understanding of the errors by identifying the root causes and being accountable for eliminating errors within their control. In addition, the radiology staff learned to accept and trust the PACS, resulting in a positive culture change that benefited teamwork and staff morale as well as improve the workflow and the quality of patient care.     

放射科工作流集成的应用实践

探讨综合性大型医院RIS/PACS建设中放射科工作流集成方案。采用I HE radiology工作流相关的4个集成模式,并根据国内需求优化应用,达到改善预定工作流、报告工作流、简化纠错流程、提高工作诊疗效率及质量的要求。重视I HE radiology集成模式应用,兼顾本土化需求,完善数字化医疗影像工作环境。