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.     

Radiology report turnaround: expectations and solutions

The ultimate work product of a radiology department is a finalized radiology report. Radiology stakeholders are now demanding faster report turnaround times (RTAT) and anything that delays delivery of the finalized report will undermine the value of a radiology department. Traditional reporting methods are inherently inefficient and the desire to deliver fast RTAT will always be challenged. It is only through the adoption of an integrated radiology information system (RIS)/picture archiving and communication system (PACS) and voice recognition (VR) system that RTAT can consistently meet stakeholder expectations. VR systems also offer the opportunity to create standardized, higher quality reports.     

Pediatric Emergency Imaging Studies in Academic Radiology Departments: A Nationwide Survey of Staffing Practices

ObjectiveParticularly for pediatric patients presenting with acute conditions or challenging diagnoses, identifying variation in emergency radiology staffing models is essential in establishing a standard of care. We conducted a cross-sectional survey among radiology departments at academic pediatric hospitals to evaluate staffing models for providing imaging interpretation for emergency department imaging requests.MethodsWe conducted an anonymous telephone survey of academic pediatric hospitals affiliated with an accredited radiology residency program across the United States. We queried the timing, location, and experience of reporting radiologists for initial and final interpretations of emergency department imaging studies, during weekday, overnight, and weekend hours. We compared weekday with overnight, and weekday with weekend, using Fisher’s exact test and an α of 0.05.ResultsSurveying 42 of 47 freestanding academic pediatric hospitals (89%), we found statistically significant differences for initial reporting radiologist, final reporting radiologist, and final report timing between weekday and overnight. We found statistically significant differences for initial reporting radiologist and final report timing between weekday and weekend. Attending radiologist involvement in initial reports was 100% during daytime, but only 33.3% and 69.0% during overnight and weekends. For initial interpretation during overnight and weekend, 38.1% and 28.6% use resident radiologists without attending radiologists, and 28.6% and 2.4% use teleradiology. All finalized reports as soon as possible during weekdays, but only 52.4% and 78.6% during overnight and weekend.DiscussionA minority of hospitals use 24-hour in-house radiology attending radiologist coverage. During overnight periods, the majority of academic pediatric emergency departments rely on resident radiologists without attending radiologist supervision or outside teleradiology services to provide initial reports. During weekend periods, over a quarter rely on resident radiologists without attending radiologist supervision for initial reporting. This demonstrates significant variation in staffing practices at academic pediatric hospitals. Future studies should look to determine whether this variation has any impact on standard of care.     

Perspectives on speech recognition technology

Speech recognition technology is used in all sorts of applications. However, for radiology, the issues are more complex than merely being able to dial a contact from an address book. In addition, radiologists have been hesitant to embrace the technology, with some preferring the status quo. Speech recognition technology has dramatically improved over the past several years, and they generally have been broadly commercialized. However, the use of speech recognition for composition of text reports or email has had only limited acceptance. The overriding reasons appear to be that most computer users prefer not to talk to their computers. They have learned to compose text documents via a "type-and-organize" methodology rather than composing the document "in their heads" and dictating. Radiologists are still required to dictate their reports, whether it is digitally, into an analog tape recording device or via a speech recognition system. The benefits extend to the radiologist's patients, and to the radiologist's employers--the hospitals or imaging centers--but it could be said that there is little direct benefit for the radiologist There is a belief that systems should focus more on improving radiologist efficiency rather than emphasizing cost savings and turnaround time. Integration with existing systems is critical. But any technology, in order for it to be well accepted by the primary user, needs to benefit that user. Before selecting any speech recognition technology a radiology administrator should do some research and find answers to several questions that address the basics of speech recognition technology and the companies that provide this technology. In addition, the radiology administrator must ensure that the facility is prepared to implement the technology and address any workflow- or culture-related issues that may arise. There are a number of opportunities for improvement in speech recognition radiology applications. These include the ongoing need for improvement recognition rates, the need to streamline integration with picture archiving and communication system (PACS) and radiology information system (RIS) technologies, and the general need to improve the user interface. In addition to these improvements, one can expect an increased adoption of structured reporting technologies within radiology. These techniques allow easier automated extraction of content and more flexible communication and organization of data (such as communication to electronic medical record systems).     

Discordance rates between preliminary and final radiology reports on cross-sectional imaging studies at a level 1 trauma center

RATIONALE AND OBJECTIVES: The goal was to determine discordance rates between preliminary radiology reports provided by on-call radiology house staff and final reports from attending radiologists on cross-sectional imaging studies requested by emergency department staff after hours. MATERIALS AND METHODS: A triplicate carbon copy reporting form was developed to provide permanent records of preliminary radiology reports and to facilitate communication of discrepant results to the emergency department. Data were collected over 21 weeks to determine the number of discordant readings. Patients' medical records were reviewed to show whether discrepancies were significant or insignificant and to assess their impact on subsequent management and patient outcome. RESULTS: The emergency department requested 2830 cross-sectional imaging studies after hours and 2311 (82%) had a copy of the triplicate form stored in radiology archives. Discrepancies between the preliminary and final report were recorded in 47 (2.0%), with 37 (1.6%) considered significant: 14 patients needed no change, 13 needed a minor change, and 10 needed a major change in subsequent management. Ten (0.43%) of the discordant scans were considered insignificant. A random sample of 104 (20%) of the 519 scans without a paper triplicate form was examined. Seventy-one (68%) did have a scanned copy of the triplicate form in the electronic record, with a discrepancy recorded in 3 (4.2%), which was not statistically different from the main cohort (P = .18). CONCLUSION: Our study suggests a high level of concordance between preliminary reports from on-call radiology house staff and final reports by attending subspecialty radiologists on cross-sectional imaging studies requested by the emergency department.     

Integration of a Community Radiology Division into a Subspecialty-Focused Academic Radiology Department

IntroductionAssimilate a general radiology division into a subspecialty-focused radiology department at an academic medical center.MethodsThis Institutional Review Board-approved quality improvement initiative was performed at an academic medical centers’ subspecialty-focused academic radiology department, aiming to assimilate a general radiology division providing interpretive services for a distributed set of community ambulatory practices. An Oversight Committee charged by the department chair created a charter with unambiguous goal, timelines, clear decision-making, and conflict resolution processes. The Committee assessed the resources and clinical capabilities of the general radiologists, and the anticipated shift in exam volume from the community into subspecialty divisions. Primary outcome, percentage of targeted organ systems-specific interpretations by general radiologists based on assigned subspecialty division, and secondary outcome of report turnaround time (TAT) for all ambulatory exams, were compared before and after sub-specialization.ResultsAmong 10 general radiologists, 4.5 were assigned to subspecialty divisions; 5.5 continued to cover an independent general radiology practice in a for-profit delivery network. In the 5 months’ post-transition, a total 86.6% (11,668/13,477) of reports by the integrated general radiologists were within designated subspecialty divisions vs 23.9% (2,586/10,829) pre-transition (P < 0.01). There was no change in ambulatory radiology report TAT for non-urgent care center (UCC) or UCC exams pre- vs post-integration.DiscussionA quality improvement initiative with unambiguous decision-making and conflict resolution processes incorporated a general radiology practice (radiologists and exams) into a subspecialty-focused academic radiology practice without negatively impacting TAT metrics. Future studies would be needed to assess impact on quality of interpretations.     

Radiology reports: examining radiologist and clinician preferences regarding style and content

OBJECTIVE: The introduction of picture archiving and communication systems (PACS) frequently includes the option of computer-generated itemized reports. This motivated us to reassess the merits of traditional prose dictated reports. This study examines radiologist and clinician preferences regarding report style and content. MATERIALS AND METHODS: The study was conducted in two parts. The first part was a retrospective audit of existing medical imaging prose reports to determine their content. The second part comprised a questionnaire containing three mock clinical scenarios. Three pairs of reports were provided for each scenario, with only essential information in the first pair, some optional information in the second, and the most complete report in the third. Each pair consisted of a prose and itemized report with identical content. Participants ranked reports by preference and were asked specific questions regarding report content. The questionnaires were mailed to referring clinicians and administered during an interactive forum to staff radiologists, radiology fellows, and radiology residents. RESULTS: The audit of existing reports showed a wide variation in all fields with consistency limited to a given radiologist. Responses to the questionnaire showed that, in general, a majority of radiologists and referring clinicians preferred itemized reports. The itemized report with the most detailed content was ranked highest of all three scenarios. CONCLUSION: Prose reports foster a lack of standardization of content among different radiologists. Itemized reports facilitate complete documentation of information and measurements and are more popular with both radiologists and referring clinicians.     

Carpal tunnel syndrome and cubital tunnel syndrome: work-related musculoskeletal disorders in four symptomatic radiologists

OBJECTIVE: This report describes work-related upper extremity musculoskeletal disorders in four radiologists and identifies risk factors and preventive measures for these syndromes. SUBJECTS AND METHODS: Four radiologists with complaints of upper extremity pain, numbness, and weakness or a combination of symptoms were examined by an occupational therapist. The work activities and duties of all 12 staff radiologists in our filmless department were subsequently evaluated. Time working as staff, workday hours, and academic activities were recorded. Nonoccupational activities were also noted. An industrial hygienist evaluated the department work areas and staff offices. RESULTS: One radiologist had bilateral carpal tunnel syndrome, and all four radiologists had cubital tunnel syndrome (two [50%] unilateral, two [50%] bilateral). The four spent 3.4 +/- 0.3 years (mean +/- standard error of the mean) as staff radiologists in our filmless department, performing computer keyboard and mouse or trackball image manipulation and work list navigation, typing preliminary reports and telephone notifications, and editing electronically and approving dictated final reports. All four are academically active and had significantly greater workday hours (p < 0.05) and performed more research (p < 0.003) than the asymptomatic radiologists. Three (75%) of four radiologists routinely performed sonography. The industrial hygienist identified hazardous working conditions, especially related to ergonomics, in the reviewing areas and staff offices. CONCLUSION: Current technology renders staff radiologists at risk for work-related, upper extremity musculoskeletal disorders, including carpal and cubital tunnel syndromes. Proper equipment, ergonomics, and professional consultation should be used in all radiology departments.     

Night radiology

Night radiology is the practice of the in-hospital radiologist from 4:00 to 11:00 p.m. His duty is to keep the interpretation of radiographs current. At the medical center described, an average of 95 radiographic examinations per day are performed during the evening and at night; 60 of these require immediate interpretation. Night radiology was instituted because of the large number of unmonitored and uninterpreted films that had to be dealt with the following morning. The night radiology duty is seven consecutive nights and is rotated among all nine staff radiologists. Night radiology provides a service that the emergency department and the private physician can rely on and can use without hesitation, delay, or resistance.     

Mala praxis: a study of malpractice claims and litigation in the field of radiology

Risk management plays an integral role in the mitigation of malpractice claims in the radiology environment. This holds true for the radiologist and professional association as well as the facility that supports the radiologic service. The radiologist and the radiology department or imaging center are separate entities which have a symbiotic relationship. Radiologists may function as an independent contractor, yet their function is dependent on the facility with which it contracts. The function of the radiology department is directly related to the radiologist's performance, staff competency, and equipment performance. Mammography poses particular concern with regard to medical malpractice, as there is an inherent subjectivity in the differential diagnosis with regard to breast cancer in mammography.     

Preliminary Reports in the Emergency Department: Is a Subspecialist Radiologist More Accurate Than a Radiology Resident?

RATIONALE AND OBJECTIVES: To determine whether emergency department (ED) preliminary reports rendered by subspecialist attending radiologists who are reading outside their field of expertise are more accurate than reports rendered by radiology residents, and to compare error rates between radiologists and nonradiologists in the ED setting. MATERIALS AND METHODS: The study was performed at a large academic medical center with a busy ED. An electronic preliminary report generator was used in the ED to capture preliminary interpretations rendered in a clinical setting by radiology residents, junior attendings (within 2 years of taking their oral boards), senior attendings, and ED clinicians between August 1999 and November 2004. Each preliminary report was later reviewed by a final interpreting radiologist, and the preliminary interpretation was adjudicated for the presence of substantial discordances, defined as a difference in interpretation that might immediately impact the care of the patient. Of the 612,890 preliminary reports in the database, 65,780 (11%) met inclusion criteria for this study. A log-linear analysis was used to assess the effects of modality and type of author on preliminary report error rates. RESULTS: ED clinicians had significantly higher error rates when compared with any type of radiologist, regardless of modality. Within the radiologists, residents and junior attendings had lower error rates than did senior attendings, but the differences were not statistically significant. CONCLUSION: Subspecialized attending radiologists who interpret ED examinations outside their area of expertise have error rates similar to those of radiology residents. Nonradiologists have significantly higher error rates than radiologists and radiology residents when interpreting examinations in the ED.     

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.     

Project planning, training, measurement and sustainment: the successful implementation of voice recognition

Computerized voice recognition systems (VR) can reduce costs and enhance service. The capital outlay required for conversion to a VR system is significant; therefore, it is incumbent on radiology departments to provide cost and service justifications to administrators. Massachusetts General Hospital (MGH) in Boston implemented VR over a two-year period and achieved annual savings of $530,000 and a 50% decrease in report throughput. Those accomplishments required solid planning and implementation strategies, training and sustainment programs. This article walks through the process, step by step, in the hope of providing a tool set for future implementations. Because VR has dramatic implications for workflow, a solid operational plan is needed when assessing vendors and planning for implementation. The goals for implementation should be to minimize operational disruptions and capitalize on efficiencies of the technology. Senior leadership--the department chair or vice-chair--must select the goals to be accomplished and oversee, manage and direct the VR initiative. The importance of this point cannot be overstated, since implementation will require behavior changes from radiologists and others who may not perceive any personal benefits. Training is the pivotal factor affecting the success of voice recognition, and practice is the only way for radiologists to enhance their skills. Through practice, radiologists will discover shortcuts, and their speed and comfort will improve. Measurement and data analysis are critical to changing and improving the voice recognition application and are vital to decision-making. Some of the issues about which valuable date can be collected are technical and educational problems, VR penetration, report turnaround time and annual cost savings. Sustained effort is indispensable to the maintenance of voice recognition. Finally, all efforts made and gains achieved may prove to be futile without ongoing sustainment of the system through retraining, education and technical support.     

The path of least resistance: is there a better route?

In May 2000, the radiology department at Stanford University Medical Center embarked on a five-year journey toward complete digitization. While the end goal was known, there was much less certainty about the steps involved along the way. Stanford worked with a team from GE Medical Systems to implement Six Sigma process improvement methodologies and related change management techniques. The methodical and evidence-based framework of Six Sigma significantly organized the process of "going digital" by breaking it into manageable projects with clear objectives. Stanford identified five key areas where improvement could be made: MR outpatient throughput, CT inpatient throughput, CT outpatient throughput, report turnaround time, and Lucile Packard Children's Hospital CR/Ortho throughput and digitization. The CT project is presented in this article. Although labor intensive, collecting radiology data manually is often the best way to obtain the level of detail required, unless there is a robust RIS in place with solid data integrity. To gather the necessary information without unduly impacting staff and workflow at Stanford, the consultants working onsite handled the actual observation and recording of data. Some of the changes introduced through Six Sigma may appear, at least on the surface, to be common sense. It is only by presenting clear evidence in terms of data, however, that the improvements can actually be implemented and accepted. By converting all appointments to 30 minutes and expanding hours of operation, Stanford was able to boost diagnostic imaging productivity, volume and revenue. With the ability to scan over lunch breaks and rest periods, potential appointment capacity increased by 140 CT scans per month. Overall, the CT project increased potential for outpatient appointment capacity by nearly 75% and projected over $1.5 million in additional annual gross revenue. The complex process of moving toward a digital radiology department at Stanford demonstrates that healthcare cannot be healed by technology alone. The ability to optimize patient services revolves around a combination of leading edge technology, dedicated and well-trained staff, and careful examination of processes and productivity.