Improving medical imaging report turnaround times: the role of technolgy

At Southern Ohio Medical Center (SOMC), the medical imaging department and the radiologists expressed a strong desire to improve workflow. The improved workflow was a major motivating factor toward implementing a new RIS and speech recognition technology. The need to monitor workflow in a real-time fashion and to evaluate productivity and resources necessitated that a new solution be found. A decision was made to roll out both the new RIS product and speech recognition to maximize the resources to interface and implement the new solution. Prior to implementation of the new RIS, the medical imaging department operated in a conventional electronic-order-entry to paper request manner. The paper request followed the study through exam completion to the radiologist. SOMC entered into a contract with its PACS vendor to participate in beta testing and clinical trials for a new RIS product for the US market. Backup plans were created in the event the product failed to function as planned--either during the beta testing period or during clinical trails. The last piece of the technology puzzle to improve report turnaround time was voice recognition technology. Speech recognition enhanced the RIS technology as soon as it was implemented. The results show that the project has been a success. The new RIS, combined with speech recognition and the PACS, makes for a very effective solution to patient, exam, and results management in the medical imaging department.     

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.     

Development of an electronic radiologist's office in a private institute.

A computer system that improves the quality, user-friendliness, accessibility, and management of radiology data (images, reports, databases, knowledge) was implemented at a private institute. A picture archiving and communication system (PACS) was integrated with the radiology information system (RIS). Two servers and 12 personal computers form the integrated system. The first server is dedicated to management and archiving of Digital Imaging and Communications in Medicine (DICOM) images. The second server is dedicated to management of the RIS and archiving of patient data (Structured Query Language database), reports (hypertext markup language [HTML]), and images in the Joint Photographic Experts Group (JPEG) format (mini-PACS). There are three main client-server networks: a common network of imaging modalities (magnetic resonance imaging, computed tomography, ultrasonography, digital radiography) and two fast Ethernet networks (the PACS network and the RIS network). The RIS-PACS is linked remotely with other workstations and servers via Integrated Services Digital Network (ISDN). Images and reports can be distributed to referring physicians in the form of multimedia HTML and JPEG documents, which can also be used for quick and easy archiving, distribution, and reviewing within the institute. However, referring physicians have been reluctant to use electronic reports and images.     

The case for RIS/PACS integration

Why integrate PACS with the RIS? To improve workflow, of course, but what workflow? Much of the focus is on improving the flow of images for the radiologist, which is certainly a good thing to do, but what about the rest of the order process? Typical PACS system architecture begins with the HIS since this is where the correct patient demographic information and in many cases the orders originate. Correct patient and order information is sent from the HIS to the RIS using HL7 commands for Admission/Discharge/Transfer (ADT) and Order/Entry. HL7 is the communications protocol used in virtually all information systems. For the first step in communicating with PACS, patient and order information from the RIS is sent to a device called a PACS broker. This is necessary because most PACS systems do not support HL7 directly, and a translation is required. Images from each imaging modality are also sent to the broker using the DICOM standard. If an imaging modality does not support DICOM, then an additional box is used to convert the images to a DICOM file. The broker then sends completed DICOM files to the PACS for storage, distribution and viewing. That approach has worked well for the first stage of PACS utilization. However, experienced PACS users have identified the need to improve workflow, and many feel that closer communication with the RIS will solve many of the current limitations. This approach is sometimes called a "brokerless" solution but is probably better described as incorporating broker functions into the RIS. There are several potential advantages of incorporating the broker functions into the RIS: Access to all RIS information on patients, orders and results is available and can be used in many ways to improve workflow. Supporting all DICOM services directly from the RIS ensures that the latest and most complete information is always used. For example, DICOM Modality Worklists can be provided directly from the RIS, which guarantees that they are updated immediately. The RIS can manage the complete order workflow, not just images. License, implementation and support costs can be reduced by eliminating HL7 interfaces to an external broker. Managing workflow is the key to improved productivity and patient care from PACS. However, coordinated management of order workflow from the RIS and image workflow from the PACS is required to get the full benefit. The RIS has immediate and broad access to patient and order information. As a result, it is the natural place to take the lead in managing this coordinated workflow. While many older RIS and PACS systems are not yet capable of some of the integration features described above, several new systems are moving rapidly in that direction.     

Wunsch und Wirklichkeit bei der Installation einer abteilungsübergreifenden Bild- und Befunddistribution

PROBLEM: This report describes the problems that can occur in the representation of the radiological workplace in a digital environment. On one hand the radiologist can sometimes access good equipment in "stand-alone" surroundings (CT, laser printer, workstations,...); on the other hand, the existing insufficient communication between different components is only rarely qualified to support the radiological workflow. This unsatisfactory framework handicaps the required clinic-wide distribution of radiological information. METHODS: From the beginning we defined user groups requiring different radiological data closely associated with specific hard- and software: The radiological workstation in the department for reporting and image processing. The demonstration workstation in wards/outpatient departments for clinicians involved in treatment. Standard PCs with access to the digital medical document for clinicians involved in treatment. At all workstations the medical as well as the legal unity of digital radiological images and the corresponding report is ensured. RESULTS: Only the first two user groups have unrestricted access to the RIS database and to the PACS archive. We have decided that the RIS should be the master of the RIS/PACS-System. For an effective master/slave relationship between RIS and PACS archive and PACS workstations we suggest to mark images and/or series of images. CONCLUSION: The third user group depends on the information exported by the radiologist from PACS. After the report is written and signed by the radiologist, the digital report is transferred from the RIS to the HIS. The report is automatically attached to these images. Authorized personnel at the wards and outpatient are able to read the combination of validated report and exported radiological images as part of the digital medical record with an intranet browser on standard PCs.     

PACS strategy for imaging centers

Picture archiving and communications systems (PACS) have been available in imaging centers for many years, but they often were less functional, were not well integrated into patient information systems, and lacked the network backbone to implement a system. As modalities are replaced and technology improves, the ability and time for an imaging center to acquire, integrate, and utilize PACS has arrived. However, each imaging center must determine why it should invest in PACS. A business plan is the fundamental need. Each imaging center must understand its target market, growth rate, and staffing plans. Additional considerations lie in current and future modality availability, the need for offsite delivery of images and reports, and the potential need for remote transmission of images. These issues must be identified and prioritized. A multidisciplinary team is essential. The most successful PACS implementation begins with complete involvement from all levels. The team should be comprised of people with complementary skills who are committed to a common purpose, set of performance goals, and approach for which they hold themselves mutually accountable. The team must jointly decide on the project's objectives. These objectives fall under 4 categories: clinical, service, financial, and performance. PACS must be considered a tool to help accomplish each objective. The imaging center must determine its top priorities, then translate them into a technology "wish list." The center can then list those pieces of technology that are most important and prioritize them. There are even more considerations for connecting multiple imaging centers. The team must create a comprehensive request for proposal (RFP) and determine the vendors that will receive the document. Once the RFP responses have been received and the vendor has been selected, an effective training plan must be executed. Training plans should be competency-based, ensuring comfort and competency among all staff. Upon the project's completion, it is essential for the imaging center to evaluate PACS' effect upon its services and relationships with patients, staff, and referring physicians. Marketing and demonstrating the latest technology can positively impact all these areas.     

PACS sans RIS

Sutter Gould Medical Foundation (SGMF) is a multi-specialty physician practice located in Modesto, CA, and is an affiliate of Sutter Health. In May 2003, SGMF embarked on the journey to install a picture archiving and communication system (PACS) in the main facility. Unique to the project was bringing the PACS live sans (from the French "without") a radiology information system (RIS) and having the PACS driven by an electronic medical record (EMR). Other challenges were present in terms of interfaces for the dictation system, delivering images to the providers on their desktop, and mimicking the referring providers workflow as much as possible in the digital environment to which they were accustomed in the "paper and film" environment.     

通过工作列表实现数字化网络各系统之间患者信息的一致性

目的 实现图像存储与传输系统(picture archiving and communication system，PACS)、放射学信息系统(radiology information systems，RIS)、影像设备之间患者检查信息的一致性。方法 我院引进GE Signa 1．5T磁共振、数字乳腺，Agfa数字X线摄影、计算机X线摄影及GE CT等数字化医学设备。GE PACS是英文系统，所以前期医院在未解决信息一致性时只通过PACS对检查影像进行保存，通过PACS系统中简单的信息管理工作，并没有真正意义上的worklist。2个月后，我院采用国际上先进的解决方法即通过医学数字成像及通讯(digital imaging and communication in medicine，DICOM)标准的工作列表(worklist)的方法实现信息的一致性。在RIS系统中将患者中文信息转换为英文信息，保存并为worklist提供患者的英文信息。结果 我院在集成PACS和RIS的2年多时间以来，通过worklist来保证RIS与影像设备患者检查信息的一致性，取得了非常好的效果。在所有诊断工作站上，诊断医生通过中文RIS系统，对病人的信息进行编辑、修改、产生。结论 通过worklist实现PACS、RIS、影像设备之间患者检查信息的一致性是可行的。     

Adding value to imaging services: a survey of patient and referring physician preferences for direct radiologic reporting of results

PurposeTo identify preferences of patients and referring physicians for direct patient communication and notification of radiologic study results.MethodsAn anonymous survey was conducted of patients undergoing outpatient radiologic imaging studies and their referring physicians. The voluntary surveys elicited responses regarding preferences on a 5-point Likert scale (Strongly disagree, disagree, neutral, agree and strongly agree), as well as indicated by responding yes or no to specific questions.Results368 patients completed the survey. 81.5% of patient responders preferred all results communicated from the radiologist within the same day. 65.9% of patients preferred same day results if normal vs 65.8% if abnormal. 34.5% preferred to wait and review normal results with the referring physician. 41.5% preferred to wait and review abnormal results with the referring physician. It was found that patients were more likely to strongly agree with waiting to review results with the referring physician if the results were abnormal, as opposed to normal (18.5% vs 11.9%, respectively; P < 0.014). 64% of physicians did not want results reviewed with their patients; 87.6% did not want a report sent to the patient by the radiologist, even after report was sent to their office. 66.4% of patients surveyed indicated that waiting for imaging results gives them anxiety.Conclusions58–82% of patients preferred same day radiologist communication of their results while 55–87.6% of physicians did not prefer same day radiologist communication of results directly with their patients. 66.4% of patients surveyed indicated that waiting for imaging results gives them anxiety.     

小型医学影像存储与传输系统的临床应用

目的 探索小型医学图像存档与通讯系统(minimizing picture archiving and communication system，mini—PACS)在实际工作中的应用，逐步实现科室内的无胶片化管理。方法 建立基于PC机的局域网，连接CT、MR、数字胃肠机、DSA、激光相机等医学影像设备，整合数字图像网络(digital imaging network，DIN)和医学图像诊断系统(medical diagnostic imaging system，MDIS)，组成放射科信息管理系统(radiology information system，RIS)。RIS系统通过其中1台安装双网卡的PC工作站与医院信息系统(hospital information system，HIS)相连。结果 系统在2年多的时间内得到连续使用，放射科信息管理系统得以实现和完善。在现有的数字化影像设备上实现了符合医学数字图像传输标准3．0(digital imaging communication in medicine，DICOM3．0)格式的图像采集、储存、传输、打印、浏览功能。图像和诊断报告信息通过Microsoft Access数据库管理，不同设备上保存的在线图像为3～6个月，所有图像用CD—R光盘刻录，作为离线永久保存，已有32700多份诊断报告存入数据库；HIS终端可有限制地从该系统获得图像和诊断信息。结论 mini—PACS系统投入和运行成本低、维护简单、性能可靠，可基本实现PACS的重要功能，在中、小医院具有良好的应用前景。     

Electronic Worklist Improves Timeliness of Screening Mammogram Interpretation in an Urban Underserved Population

ObjectivesTo evaluate the impact of an electronic workflow update on screening mammography turnaround time and time to diagnostic imaging for mammography performed on our urban mobile mammography van and at an urban community health center.MethodPrior to 10/15/2019, screening exams for the mammography van and urban community health center were made available for interpretation to a single designated radiologist via a manually generated paper list. On 10/15/2019, screening exams were routed electronically onto PACS for any breast radiologist across our Network to interpret. Screening mammogram turnaround time (defined as time form image acquisition to report finalization), time to diagnostic imaging, and time to tissue sampling were collected for pre- and post-implementation periods (6/1-9/30/2019 and 11/1/2019-2/29/2020, respectively) and compared via student t-test and statistical process control analyses.ResultsThe number of screening exams in the pre- and post-implementation periods were 851 and 728 exams, respectively. Patients were predominately Black and/or African American (400/1579, 25%), non-English speaking (858/1579, 54%) and insured by Medicaid (751/1579, 48%). After implementation of the electronic workflow, turnaround time decreased from 101.0 to 36.4 hours (63.9%, P <0.001) and statistical process control analyses showed sustained decrease in mean turnaround time. However, mean time to diagnostic imaging and tissue sampling were unchanged after implementation (39 vs 45, days; P = 0.330 and 43 vs 59; P = 0.187, respectively).ConclusionElectronic workflow management can reduce screening mammography turnaround time for underserved populations, but additional efforts are warranted to improve time to imaging follow-up for abnormal screening mammograms.     

Data security assurance in CAD-PACS integration.

Computer aided diagnosis/detection (CAD) has been extensively used in mammography, chest, and three-dimensional (3D) CT lung imaging for clinical decision support over last 5-6 years. Recent trend is to integrate CAD applications with a PACS so that CAD results can be reviewed by most physicians for diagnosis. However, data security issue arises when a CAD application is integrated with a PACS. In this paper, we present a lossless digital signature embedding (LDSE) method for assuring the integrity of images used by the CAD and new images and results generated by the CAD application. Our experimental results show that the method is effective for assuring the integrity of CAD images. Combining this method with traditional one-dimensional digital signature technique for protecting CAD results, we provide a complete integrity assurance solution for a CAD application integrated with a PACS.     

Paperless medical records: moving from plan to reality

In 2002, North Shore Magnetic Imaging Center (NSMIC) decided that a major restructuring of the patient process was necessary to alleviate staff frustration and increase the level of patient care. An aggressive, 16-month timeline was established for the center to develop and implement a paperless environment. The project began by focusing on the center's existing radiology information system (RIS). Research showed that no "canned" system would perform the necessary tasks. The center's vendor, with whom senior management had developed a longstanding and trusting relationship, assured the center that, with the proper programming, the existing RIS could support the new paperless environment. Additional technology components were addressed. The first phase enabled staff to obtain physician orders and outside reports from the fax server. Once the patient medical record was fully electronic, these external documents were no longer printed. The transfer of billing information to the radiologist's billing office was achieved through a Health-Level 7 (HL7) interface between NSMIC's RIS and the information systems utilized by the billing office. Technologists were impacted when wireless personal computer (PC) tablets were implemented. Measuring 8.5" x 11" x 0.5", these tablets enable technologists to gather and record patient information while moving freely throughout the center. Forming the Reinvention Team--an internal team of NSMIC staff that would deal with the project's impact on staff, workflow, and patient care--was done in very deliberate fashion. During the recruitment phase of the project, each prospective team member was required to take 2 specific personality profile tests. The team was comprised of a combination of different personality profiles. A radiologist was later added to the team. Throughout the implementation of new processes at NSMIC, numerous breakdowns were encountered. The breakdowns could be classified into 2 categories: technical andpatient-related. Breakdowns were addressed during the Reinvention Team's weekly meetings. A patient's experience at NSMIC has changed dramatically with the implementation of electronic medical records. More patients are able to complete their exam without experiencing anxiety, or even at time claustrophobia, because they are more at ease. The rate for patients becoming claustrophobic has seen a decrease from 1.9% to 0.99% in the past 12 months.     

Medico-legal issues in radiological consultation

Providers increasingly use radiological services for diagnosis and treatment. Both the referring physician and the radiological consultant can contribute to efficient and effective consultation, and direct interaction may facilitate the process further. Furthermore, inadequate communication can influence poor patient outcome. We examine the roles and responsibilities of referring physicians and consultant radiologists, and present a malpractice case, Townsend v. Turk 218 Cal. App. 3d 278 (1990), to identify medico-legal issues in radiological consultation. Important issues are implied by the Townsend case. First, it is the clinician's responsibility to include clinical information that is appropriate and adequate. Further, the radiologist is a valuable resource in the selection of the optimal procedure, provided that he or she is aware of the patient's history. The second issue discussed by the court represents a possibly more pervasive problem. The interaction between a consulting radiologist--indeed any specialist--and a treating physician is subject to difficulties caused by different conceptions of professional boundaries. The position taken by the court in the Townsend case is consistent with the traditional view that a consulting radiologist has an attenuated duty to the patient. It also would seem to receive at least some support from the language contained in the current revision of the ACR Standard for Communication: Diagnostic Radiology, effective Jan. 1, 2002: ...The referring physician or healthcare provider also shares in the responsibility of obtaining results of imaging studies they have ordered. Despite the result of the Townsend case and the current formulation of the ACR Standards, however, radiologists face risks of litigation. Indeed, the emerging trend in radiological consultation is the direct communication of results to the patient. It is clear that improved communication between radiologists and referring physicians is both desirable and imperative. Clinico-radiological encounters yield additional clinical information and guide the decision-making process. In the Townsend case, direct interaction would have resolved ambiguity.     

HIS/RIS/PACS integration: getting to the gold standard

The technology for acquiring, storing, retrieving, displaying, and distributing images has advanced dramatically in recent years. The push is toward enterprise-wide image management solutions, where digital images from radiology, cardiology, and other "ologies" are seamlessly linked with information from clinical information systems and other databases, and they are accessed seamlessly from a single point of end-user interaction. The "gold standard" of system integration would provide the platform for improved workflow, patient throughput and patient safety, as well as decreased cost. Unfortunately, the gold standard remains elusive in most healthcare environments, even those with new systems. One of the earliest issues that plagued the progress of hospital information system/radiology information systems/picture archiving and communication systems (HIS/RIS/PACS) integration was a matter of language between Health Level-7 (HL7) and DICOM. This barrier was solved by the broker--a software and hardware device that accepts HL7 messages from the RIS then translates, or maps, the data to produce DICOM messages for transmission to the PACS. Technologist workflow requires patient and exam information from the RIS to flow to the modality. The broker provides support for this by taking advantage of the DICOM Modality Worklist (DMWL). Two primary problems are inherent in most brokered configurations. Workflow is driven by paper, and RIS information flows in 1 direction only, which leads to duplicative databases. Overcoming the limitations of HIS/RIS/PACS connectivity requires industry accepted communication protocols/rules. To facilitate this, the Integrating the Health Care Enterprise (IHE) initiative was developed. The goal of IHE is to provide end-users improved access to critical patient and clinical information across all systems within the healthcare delivery network. While the IHE initiative began to facilitate more efficient, predictable, and functional integration between disparate systems, vendors still had technology hurdles to overcome. System integration continues to be significantly hampered, not by technology limitations, but instead by business and political issues. In response to these challenges, several vendors have begun to offer consolidated RIS/PACS solutions and/or HIS/RIS/PACS solutions. Consequently, the prospect of the gold standard appears to be on the horizon. Single vendor consolidated systems are not, however, feasible for deployment in many healthcare organizations, and they are not necessarily the panacea.     

The radiologist and the patient: breaking bad news.

Radiologists may be asked to disclose results directly to patients. Studies of radiologist-patient communication show that radiologists have a direct responsibility to their patients, that many patients wish to learn the results of imaging tests from the radiologist at the time of the examination, and that many referring physicians support the principle of radiologists disclosing results when patients ask for them. In some areas, such as breast imaging and interventional radiology, disclosure by radiologists is very common. The authors, who work in a perinatology unit in which obstetrical ultrasonography is performed, have developed a template to help them with the often-emotional interactions associated with pregnancy failure. They recommend that radiologists inform the patient clearly of the examination results, choosing everyday words such as "miscarriage" and "pregnancy." They also recommend that physicians show compassion, acknowledge patients' grief and inform the referring physician as soon as possible. These steps should be part of a policy of direct, honest communication with patients.     

PACS for imaging centers

PACS can be a difficult and confusing decision for any radiology provider, but it can be an even more dynamic question for an outpatient imaging center. Every center represents a unique situation and requires a specialized solution. Typically, most of what is said and discussed about PACS concentrates on solutions and requirements for hospital radiology facilities. Administrators of imaging centers have different problems from hospital administrators, and they need different answers. For imaging centers, the financial justification for PACS may be less immediate than for hospitals. The first thing that must be understood is that no PAC system can make a typical imaging center completely filmless, at least not for quite a while. A hospital has the ability to dictate to its internal referring physicians how a radiological study is delivered, whereas in an imaging center environment, the roles are very much reversed. Once the justification are made for the financial viability of PACS in an imaging center, the next question is how to finance the acquisition of PACS. The decision will depend on how you cost justify your PACS, as well as the shape of your business model, and it will come to a decision between capital purchase or contracting with an application service provider, or ASP. Historically, in the hospital-dominated marketplace, PAC systems have been treated as capital acquisitions. However, for most imaging center, owning the system is more of a problem than a benefit. ASPs increasingly represent a successful alternative for imaging centers. One of the biggest things to consider with PACS is how to store all of those images. There are typically two options, on-site and off-site, with a new "hybrid" option surfacing more recently. Each option has benefits for the user, but the benefits of off-site storage are increasing as the technology advances. Some of the benefits are data security and access. Other issues to address are HIPAA compliance, standardized interfaces such as HL-7, Web access and the choice of view stations.     

图像存储与传输系统的总体设计与分步实施

目的 探讨在组建图像存储与传输系统（picture archiving and communication system,PACS)过程中的总体设计及如何进行具体每一步的实施方案。方法 把具有医学数学成像及通讯（digital imaging and communication in medicine,DICOM)标准接口或非DICOM标准接口的影像设备进行联网，制定资源共享、系统存储的解决方案，建立典型的医院放射科PACS系统，连接目前医院现有的设备，服务器采用Windows NT SQL Server 7.0组成，解决管理及存储问题，工作站基于浏览（WEB）方式访问，扩大客户端的使用权限（license)，数量为100个，磁盘阵列（RAID 5）在线存储3个月，线性磁带库（DLT)离线海量存储；扩展全院并解决放射学信息系统（radiology information systems,RIS)、PACS的数据共享连接；建立地区影像数据交换中心。结果 建立了典型的医院放射科PACS系统，连接了目前医院现有的设备，实现了放射科初步的无胶片化方式；将PACS扩展到了全院的临床科室、手术室、急诊室等，以及实现了和已有的医院信息系统（hospital information systems,HIS)、其他医院网络联网，建立起了影像数据中心；实现了和本地区其他医院及其他地区的影像数据中心的联网，使用起来较为得心应手，方便了医生，提高了工作效率。结论 实践证明，上述PACS的总体设计与分步实施方案是可行的、成功的。