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.     

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.     

Increased productivity of a digital imaging system: one hospital's experience.

During peak hours of operation, it was not uncommon for the radiology department at St. Luke's Episcopal Hospital in Houston, Texas, to have a backlog of six to ten patients. While some of this was due to competing schedules from the emergency department (ED) and inpatients, the major problem was an inefficient workflow, especially for emergency department patients. Our staff in the radiology department worked with the hospital management to include plans for a new radiology room in an ED renovation project. In designing the new radiology room the most important issues under consideration were the physical location of the room and the type of radiography system to be installed. With plans to implement PACS, we evaluated computed radiography and digital radiography options. At St. Luke's, we had had our first experience with digital radiography after the purchase of a dedicated digital chest system. As a beta test site for the manufacturer, we had an opportunity to test--what was at the time--a new digital radiography system. The powerful impact of digital radiography became most evident by the decreased patient backlog. Even without PACS, workflow became dramatically more efficient. Images now are available for review within seconds after exposure, since there are no films to process. This has reduced our average exam time from ten minutes to one and a half minutes, not including patient transport time. The efficiency demonstrated with the digital chest system provided evidence that digital systems could handle significantly more patients than computed radiography or screen-film systems, without a compromise in image quality. Therefore, we decided to put a digital radiography system in the new ED radiology room. We estimate that the new unit will pay for itself in less than three years.     

Emergency physician error rates for interpretation of plain radiographs and utilization of radiologist consultation

Emergency physicians’ errors of interpretation of plain radiographs and these physicians’ utilization of radiologist consultation services were studied. During daytime hours over a 3-month period, 953 radiograph packets on emergency department patients were reviewed in the radiology department after initial interpretation by an emergency department physician. Consultation requests and clinically significant discordances between radiology and emergency department interpretations were tabulated. Discordances were categorized by the type of examination and the type of error. The time between each packet’s arrival in the radiology department and issuance of a report was recorded. After completion of data collection, all of the discrepant cases were reviewed by a staff emergency room physician and a staff radiologist to establish the proper interpretation and the source of the discordance. Radiologist consultation was requested for 106 (11.1%) of the packets. Of the 847 packets for which the emergency room physician did not request radiologist consultation, radiologist and emergency physician interpretations agreed in 776 (91.6%) and were discordant in 71 (8.4%) of the packets. Of 65 cases available for discrepancy review, the reviewers agreed with the radiologist’s interpretation in 60 (92%) of the cases and disagreed in 5 (8%) of the cases. Ten (17%) of the discordances were the result of overcalls, 47 (78%) were the result of overlooked findings, and 3 (5%) were the result of misinterpretations of findings. Sixty-eight percent of the discordances in interpretation were made to chest studies, 15% to abdominal studies, and 17% to musculoskeletal studies. Emergency physicians at the study institution requested consultations from a radiologist in 11.1% of cases. They made potentially important errors on independent interpretation of plain radiographs in 60 of 847 (7.1%) of cases for which consultation was not sought. Radiologists misinterpreted radiographs in 5 cases. These data suggest that radiologists play an important role in emergency health care delivery and should continue to routinely interpret all emergency department radiographs.     

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.     

Clinical consequences of misinterpretations of neuroradiologic CT scans by on-call radiology residents

BACKGROUND AND PURPOSE: Studies have looked at the accuracy of radiologic interpretations by radiology residents as compared with staff radiologists with regard to emergency room plain films, emergency room body CT scans, and trauma head CT scans; however, to our knowledge, no study has evaluated on-call resident interpretations of all types of neuroradiologic CT scans. Both as a part of our departmental quality control program and to address concerns of clinical services about misinterpretation of neuroradiologic CT scans by on-call radiology residents, we evaluated the frequency of incorrect preliminary interpretations of neuroradiologic CT scans by on-call radiology residents and the effect of such misinterpretations on clinical management and patient outcome. METHODS: As determined by the staff neuroradiologist the next day, all potentially clinically significant changes to preliminary reports of emergency neuroradiologic CT scans rendered by on-call radiology residents were recorded over a 9-month period. A panel of neuroradiologists reviewed and graded all the changed cases by consensus. An emergency department staff physician reviewed medical records of all submitted cases to determine clinical consequences of the misinterpretations. RESULTS: Significant misinterpretations were made in 21 (0.9%) of 2388 cases during the study period. There was a significant change in patient management in 12 of the cases, with a potentially serious change in patient outcome in two cases (0.08%). CONCLUSION: On-call radiology residents have a low rate of significant misinterpretations of neuroradiologic CT scans, and the potential to affect patient outcome is rare.     

Process reengineering for the filmless environment.

Facilities that are converting to filmless operations can learn from the University of Kentucky Chandler Medical Center's (UKMC) experience: that dramatic reengineering processes must take place before radiologists' productivity can increase. To convert a radiology department to soft copy interpretation, a piece-by-piece implementation of new systems or upgrades is customary. The first step may be to link each modality that is already digital into modality-specific mini-PACS, then to link the mini-PACS. Bringing other modalities on-line as new equipment is purchased and expanding the image information system (IIS) to the remainder of the healthcare facility rounds out the transition and may take several years. The downside of this kind of evolutionary approach is that the radiology department temporarily operates in two environments, the traditional film and the new filmless environments. To make the move from film to filmless, an administrator and the radiology staff must reengineer nearly every departmental process. Total quality management (TQM) techniques offer tools that are ideal for the task. Other recommendations include using a multidisciplinary team of staff members who are familiar with film-handling to create flow charts of all departmental processes. Each step should be validated to show its value to the overall process, the department or the institution. Next, flow charts of the expanded or new processes should be developed with input from the IIS manager, referring physicians and key IS personnel. Follow with estimates of staffing requirements that meet the needs of the completed flow charts and, finally, train staff members for the implementation of the new processes.     

Delivering radiology supplies just-in-time.

The radiology department at Dartmouth Hitchcock Medical Center (DHMC) adopted a just-in-time (JIT) inventory management system in 1992, reducing the volume of its in-house inventory of radiology supplies from a value of $400,000 to $16,000, just enough for four to five days of activity. An asset manager, the only person authorized to order supplies, was given responsibility for maintaining the department's supply of fixed and consumable assets. The first step in implementing the new system was to identify the supplies needed, standardize them and determine how often deliveries would be made. The JIT implementation team developed a request for proposal (RFP) that incorporated the standardized list of supplies. Three radiology supply vendors were invited to respond to the RFP. The team later determined that only one vendor was capable of implementing the JIT program. A three-year contract was awarded to that vendor. As that three-year contract reached completion, DHMC offered the JIT program to its eight affiliate hospitals and four outpatient clinics. The team decided to re-bid the contract for the entire network, which collectively performed 700,000 radiology exams annually. The new RFP encompassed 90 percent of the network's consumable supplies and offered customized delivery for each facility. The team identified eight criteria necessary for the evaluation of each vendor response to the RFP, rather than use price as the only consideration. The company that won the three-year contract furnished 90 percent of the radiology supplies for the DHMC network, allowing even further savings by the network, particularly for the smaller facilities and clinics. The program is continually monitored, adjusted and enhanced in order to incorporate changing departmental needs.     

Emergency radiology services at medical schools in the United States.

RATIONALE AND OBJECTIVES. Little has been published on the delivery of emergency radiologic services in academic radiology training programs. METHODS. The author surveyed 127 medical schools in the United States concerning aspects of radiology services for their emergency rooms, including who interprets images, what training in emergency radiology is provided, and problems with film retrieval. RESULTS AND CONCLUSIONS. Emergency department radiographs most often are initially interpreted by a radiology resident and subsequently reviewed by a faculty radiologist who does not have a major interest in or time commitment to emergency radiology. Most schools describe problems such as disappearance of emergency department films and a paucity of provided clinical information. Only one third of schools provide formal instruction in emergency radiology for their radiology residents.     

The Battle Against Coronavirus Disease 2019 (COVID-19): Emergency Management and Infection Control in a Radiology Department

ObjectiveTo describe the strategy and the emergency management and infection control procedure of our radiology department during the coronavirus disease 2019 (COVID-19) outbreak.MethodsWe set up emergency management and sensing control teams. The team formulated various measures: reconfiguration of the radiology department, personal protection and training of staff, examination procedures for patients suspected of or confirmed with COVID-19 as well as patients without an exposure history or symptoms. Those with suspected or confirmed COVID-19 infection were scanned in the designated fever-CT unit.ResultsFrom January 21, 2020, to March 9, 2020, 3,083 people suspected or confirmed to be infected with COVID-19 underwent fever-CT examinations. Including initial examinations and re-examinations, the total number of fever-CT examinations numbered 3,340. As a result of our precautions, none of the staff of the radiology department were infected with COVID-19.ConclusionStrategic planning and adequate protections can help protect patients and staff against a highly infectious disease while maintaining function at a high-volume capacity.     

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%.     

Scheduling: if your RIS cannot, perhaps your HIS can

As the services radiology departments provide have proliferated--new modalities, additional procedures--the scheduling process has become more complex. Radiology departments have been criticized by referring physicians and their staff for difficulties they encounter when scheduling patients for procedures. In light of managed care and increased competition for outpatient services, scheduling systems should be designed with the referring physician's office as the prime customer. Vanderbilt University Medical Center (VUMC) has devised a collaborative, hospital-wide system for scheduling. The same system is used by The Vanderbilt Clinics, which refer a significant number of outpatient procedures to VUMC. The radiology department has tailored the system to its technical requirements, and clinic staff members can access the system directly to schedule patient appointments. Minor adjustments were made during implementation of the process. Now, appointments are made efficiently by the clinic staff, and other systems, such as the film library, are benefiting from better information and organization. VUMC has changed the scheduling process of the radiology department to reach the customers who actually promote the radiology practice. Communication between the department and the clinics has improved and a spirit of teamwork is growing.     

Infection control in interventional radiology: good practice guideline

PURPOSE: In 1997, two studies were performed in interventional radiology units, one of them by the CCLIN Paris-Nord and the other, by the staff of the vascular radiology department of Hautepierre Hospital of Strasbourg in collaboration with the CCLIN Est. The results have shown poor compliance with recommended infection control guidelines and standard precautions. A working group was set up by the CCLIN Paris-Nord, with radiologists, radiology technicians, nurses and infection control practitioners to elaborate guidelines for infection control practices in interventional radiology. Materials and methods. These guidelines were compiled using legislation, consensus or expert conferences, evaluations or studies which had demonstrated a benefit to prevent infectious risk. The working group also formulated its own recommendations when no pre-existing document was available. These recommendations have been categorized according to evidence of benefit in infectious risk prevention. RESULTS: Guidelines are divided in two parts. The first part describes rooms and optimal architecture of the interventional radiology unit, flows (patients, staff, material, linen and waste), type of floor and furniture surfaces, and environment of the interventional unit (air, water, room and device cleaning). The second part details staff garments, hand washing procedures according to tasks, and protection against accident for the staff (accidental blood exposure, antimitotic drugs). Recommendations have been elaborated for patients'skin preparation and equipment handling (contrast product, automatic injector, US, scanner). A proposal for work organization is made regarding nursing protocols, documents of maintenance, surveillance of medical devices.     

Integrating your radiology information system in a complex computing environment

Radiology departments are a major source of important information regarding patient care. Such information is valuable in its own right but also provides significant added value when correlated with other information, including other clinical diagnoses, therapies, utilization, costs of care and outcomes. In the past, hospitals/imaging centers have typically sought the "best" RIS to meet the needs of the department and its user constituencies (physicians, nurses, medical records, etc.). Function and feature drove the RIS selection process. "Best of breed" was the rallying cry. Having multiple systems and vendors requires information systems and departmental staff to maintain expertise and support in each system and to interact with each vendor. The best-of-breed approach has a number of hidden costs. Before buying, ask "Is the best-of-breed RIS so much better than a more integrated solution that the support and integration efforts are worth it?" This is a complex question involving true needs, perceived needs, wants (justifiable or not), ego, politics, institutional future plans and more. Effective integration in a complex computing environment involves both technical processes and people processes. A cooperative, team-oriented process with the appropriate allocation of staff functions based on expertise and experience is needed. In general, the radiology department is best able to manage operations of the RIS. The information systems department should retain responsibility for housing the RIS computer and performing routine backup procedures as well as monitoring RIS performance. Both organizations can contribute to a highly successful integrated system operation based on their respective knowledge and experience. The IHE (Integrating the Healthcare Enterprise) is a joint initiative of the RSNA and HIMSS (Healthcare Information Systems Society) to stimulate the integration of information and imaging systems. The initiative will promote enterprise-wide sharing of data via established standards. The organizations, at their annual national meetings, will provide a visible forum and showcase of integration capabilities (most recently at HIMSS 2000).     

The “night stalker” effect: Are quality improvements with a dedicated night call rotation sustained?

The authors assessed whether the addition of a second-year diagnostic radiology resident assigned to cover the night shift at a major urban university hospital has a sustained effect on the number and clinical significance of “missed” radiologic findings. Radiographs interpreted overnight in the emergency department by radiology residents between January 1992 and December 1992 were reviewed daily by emergency radiology attending staff. A list of patients for whom there was a modification in the final radiologic interpretation was given to the emergency department physicians, who reviewed each case, scored the urgency of patient recall, and estimated the likelihood of patient morbidity attributable to the miss. The relative performance of after-hours residents was compared on the five nights per week with the dedicated night resident vs. the two nights per week without the dedicated night resident (control group). Of 22,295 after-hours examinations performed during the study period, 304 (1.36%) misses were recorded, nearly identical to the miss rate for the preceding 6 months. The percentage per examination interpreted (and number) of missed cases stratified by recall score for the control and dedicated night resident groups, respectively, were: (a) immediate, 0.62% (34) and 0.29% (49); (b) within 48 hours, 0.31% (17) and 0.32% (54); (c) no recall, 0.71% (24) and 0.29% (39); (d) finding already recognized by emergency department physicians, 0.44% (24) and 0.23% (39); total, 2.09% (114) and 1.13% (190). The difference in total discordance rates is statistically significant (P < 1 × 10⁻¹⁵). Our previously reported improvement in the quality of after-hours radiographic interpretation due to the addition of a dedicated night shift resident is sustained in a new group of residents. This confirms that the improvement is real and not a manifestation of the measurement methods.     

Multi-institutional analysis of computed and direct radiography: part II. Economic analysis

PURPOSE: To compare economic aspects of equipment configurations, productivity levels, and patient waiting times in the performance of computed radiography (CR) and direct radiography (DR). MATERIALS AND METHODS: The study received internal review board exemption status, without the need for informed patient consent. Data from four study sites were used to calculate the CR-DR crossover point (defined as the point at which the cost-effectiveness of DR equals that of CR) and CR-DR annual cost differentials. Analyzed variables included equipment and operating costs, examination volumes, and productivity. A program was developed to simulate patient arrival times, number of patient examinations, and patient waiting times on the basis of average annualized parameters for each of the four clinics. Sensitivity analyses were conducted to assess utilization rates and determine cost optimization. Utilization rates were compared with the number of excess long-stay CR patients (ie, patients who spent more than 30 minutes waiting in the radiology department prior to CR examination) and with the cost (per excess long-stay CR patient who waited more than 60 minutes) averted by using DR. RESULTS: Excess annual costs for DR over CR at the four sites ranged from $50,757 to $75,303. At extrapolated levels of economic penalties for long waiting times, the crossover point at which the DR cost became justifiable was when CR capacity utilization rates approached or exceeded 80%. CONCLUSION: In the current practice environment, with capacity utilization rates well below 80%, CR is likely to be a more cost-effective technology for the majority of general radiography providers.     

The current status of faculty staffing and resident training in emergency radiology. Results of a survey

The results of a survey of United States and Canadian radiology residency programs in hospitals maintaining major emergency departments indicate that (1) radiologic faculty assignment to emergency medicine may include "all faculty," "specific faculty," "specific and other faculty," "general," and "musculoskeletal" faculty; (2) a chief of emergency radiology section is designated in less than 35% of radiology departments providing emergency room services; (3) radiology resident rotation in emergency radiology occurs in less than 2/3 of the surveyed programs; and (4) radiology resident experience in emergency radiology ranges from two to 16 weeks in 40% of these programs, the remainder being "unspecified." The effect of this circumstance upon the emergency department patient care and resident teaching in emergency radiology is discussed and remedial suggestions presented.