Transcript View Slide Presentation - Association for Pathology Informatics

The radiology experience with
adoption of standards: enhancing
productivity and workflow
Steven C. Horii, MD, FACR, FSCAR
Department of Radiology
University of Pennsylvania Medical Center
APIII 2006 © Steven C. Horii
Disclosure
• Receive royalties from SPIE for a
book I co-edited
• Member of an Advisory Board for
Philips/Stentor, Inc.
• Compensated speaker for Philips
Medical Systems, Inc.
Introduction
• Workflow in radiology and
pathology
• Real radiology workflow
• The problem of multiple systems
• The pressure to change
• DICOM
Introduction
• Is DICOM enough?
• Integrating the Healthcare
Enterprise (IHE)
• Examples of the impact of IHE
• IHE and pathology
The perception of pathology and
radiology
• The Departments of a hospital
that make money:
– Pathology
– Radiology
– The cafeteria
– The gift shop
Radiology workflow: the “black
box” view
• Requests go into the department
• Images and reports come out
• In this respect, workflow in
radiology and pathology is
perceived to be very similar by
referring physicians
Radiology workflow: the insiders
view
• Workflow is very complex
– Multiple systems are involved
– Multiple personnel roles are
involved
– Tasks and events have a specific
sequence
– It is difficult for every person to
know the entire workflow
Multiple systems
• Image acquisition
– Radiography, CT, MR, NM, US, etc.
– Also our “interface” with patients
• Image acquisition is where
DICOM has has its greatest
success
Multiple systems
• Radiology information system (RIS)
– Scheduling
– Order entry
– Report database (transcription is often
separate)
– Patient demographics
– Examination management (more
important in film-based operations)
Multiple systems
• Digital image management
system (DIMS, PACS)
– Image capture
– Image storage
– Image display and distribution
– Examination management (the
filmless version)
Multiple systems
• Dictation/transcription system
– Conventional dictation (tapebased)
– Digital dictation (digital voice files)
• Both involve a person
transcribing the report into the
RIS
Multiple systems
• Newer methods
– Speech recognition
– Structured reporting
• Though there are some “manual”
variants, these both involve
radiologist input to a system that
outputs a text report to the RIS
Multiple systems
• Hospital information system
(HIS)
– Patient information database
– Physician order entry
– Report distribution
– Interface for laboratory
information, electronic chart
applications, etc.
The pressure of time
• Paul Chang: “Radiologists used to
hide behind the inefficiencies of
film.”
– The time-consuming nature of various
steps meant that radiologists could do
things like “batch read”
– Any delays resulting from such
workflow were buried in the other
workflow steps
Workflow delays
• Transcription typically picked up
tapes at the end of the day and
worked overnight
• The radiologist would sign reports
the next morning
• Given this, delaying interpretation
until mid-day and late afternoon did
not change the time the reports were
available
What began to change
• Digital dictation
• Reimbursement changes
• Speech recognition and
structured reporting
Digital dictation
• Transcription services could
work as reports came in
• Turn-around time (TAT) began to
decrease from 12 or more hours
to several hours
Reimbursement changes
• CMS reduced reimbursement rates
for imaging procedures, physician
appointment durations, and hospital
stays
– Pressure for reduced hospital stays
– Pressure for short “workup” cycles
– Need to see more patients or perform
more studies in the same amount of
time
Speech recognition and
structured reporting
• Reports are essentially complete
when the “dictation” is done
• Report TAT now could be down to
minutes
• A great boon to referring physicians
• More work for the radiologist (acting
as an editor)
Actual problems with speech
recognition
•
•
•
•
•
•
Wreck a nice beach
Recognize speech
Left incite you
Left in situ
Violently benign
8.9
What does radiology workflow
look like?
• Based on Integrating the Healthcare
Enterprise
• A joint effort of:
– The Radiological Society of North
America (RSNA)
– The Health Informatics management
Systems Society (HIMSS)
– American College of Cardiology (ACC)
Model of radiology workflow
report
report
Registration
report
Report
Repository
HIS patient
Diagnostic
Workstation
information
PACS
Film
Lightbox
images
retrieved
Orders Placed
examination orders
RIS
Orders Filled
procedure
scheduled
Image Manager
Prefetch any relevant
& Archive
prior studies
Acquisition
modality
images
Modality
worklist
stored
acquisition
completed
acquisition
images
in-progress
completed
printed
Modality
Film
Folder
Film
Workflow is actually worse than
this
• Eliot Siegel: in a film-based
environment with no PACS or RIS:
request to report ; 59 steps
• Our study (ultrasound): in a PACSbased environment with an RIS, but
no interface between the systems:
request to report ; 32 steps
What standards have helped
radiology?
Imaging equipment
Interface
Other devices (storage, etc.)
The standard for this is DICOM
• Move images from image generating
equipment to other devices or
systems
– Typically to a PACS
– Occasionally to printers or CD
recorders
– What constitutes “imaging equipment”
has been steadily expanding
Benefits of DICOM
• Enabled PACS
• Elimination of custom interfaces and
the problems associated with them:
– High cost of the interface and its
maintenance
– Problems every time there is a change
in the imaging equipment or PACS
Is DICOM alone sufficient to
improve workflow?
• DICOM information object
definitions include many
elements that should contain
information already in other
systems
• How does it get from these into
the DICOM metadata?
DICOM and other information
systems
• DICOM included “hooks” that
were intended for interfacing to
other information systems (e.g.,
the patient name structure and
date-time elements)
• Most other information systems
“speak” HL7, not DICOM
Why not a DICOM – HL7
translator?
• Both DICOM and HL7 suffer from a
similar problem:
• DICOM and HL7 have many options,
though DICOM structure is more
tightly defined
• How do two systems using different
options in these standards
communicate?
• Not well
Enter IHE
• In 1997, recognizing the need for
PACS to interface with other
information systems the RSNA and
HIMSS began the IHE effort
• IHE:
– Does not develop new standards
– Does develop “profiles” that specify
options within standards for particular
tasks
Some IHE terminology
• Actor: the application or system that
is responsible for certain information
or tasks; products may include one
or more actors
• Integration profile: the precise
description of how standards are to
be implemented to address a
particular clinical integration need
One example: Scheduled
Workflow (SWF) profile
• In DICOM:
– Modality Worklist: Allows imaging
equipment to request patient
demographic information from an
information system
– Performed Procedure Step: Allows
imaging equipment to send a
notification that a procedure step has
been completed
One example: Scheduled
Workflow (SWF) profile
• In HL7 specifies Actors for:
– ADT/Patient registration
– Order Placer
– Order Filler
– Image Manager
• Plus the transactions to support
these
Scheduled Workflow Profile
report
report
Registration
report
Report
Repository
HIS patient
Diagnostic
Workstation
information
PACS
Film
Lightbox
images
retrieved
Orders Placed
examination orders
RIS
Orders Filled
procedure
scheduled
Image Manager
Prefetch any relevant
& Archive
prior studies
Acquisition
modality
images
Modality
worklist
stored
acquisition
completed
acquisition
images
in-progress
completed
printed
Modality
Film
Folder
Film
What does this mean?
• In both our study and that by Dr.
Siegel, implementing SWF:
– Reduces 32 steps, or
– Reduces 59 steps
– To 9 steps
What is the productivity impact
of such reductions?
• We did a study of technologist task
time in ultrasound
• This involved the manual equivalents
of DICOM Modality Worklist and
Performed Procedure Step
• The median time was 5 minutes per
patient
The impact of small times with
large volumes
• We do approximately 20,000
ultrasound examinations per
year
• That 5 minutes per patient works
out to 69 person days per year!
The impact of small times on
productivity
• The same 5 minutes per patient,
given typical sonographer workload
in our Section, means enough time to
scan at least one additional patient
per sonographer per day
• For our section, that means 10
additional patients per day, or 2500
per typical work year
This is just one IHE profile –
there are more
• At present, approximately twenty
profiles are developed or in “trial
implementation” stage
• That does not include profiles
developed for cardiology
Other profiles that are likely to
be of interest in pathology
• Patient Information
Reconciliation – how you
reconcile the patient information
in studies done before a patient
is identified (e.g., the
unconscious patient in the
Emergency Department)
Other profiles that are likely to
be of interest in pathology
• Consistent Presentation of Images –
how do you assure that images will
look the same across many different
displays
• Key Image Note – support for
identifying the “key” images in an
examination (e.g., slide fields
showing pathology of interest)
Other profiles that are likely to
be of interest in pathology
• Charge Posting – how information
that resides in image management
systems can be made available to
billing systems
• Portable Data for Imaging –
consistent way to record images on
removable media (e.g., CD ROM)
Other profiles that are likely to
be of interest in pathology
• Post Processing Workflow –
supports additional image
processing by specialized systems
– For radiology, 3D graphics systems
– For pathology, potentially special
staining or processing/imaging
(immunofluorescence, electron
microscopy)
IHE and pathology
• Since I am not an expert in
pathology workflow, it is likely
that there are other profiles of
interest,
• But also likely that many would
need extension or additional
specification
Where to find out more
• The IHE Radiology User’s
Handbook (a must!):
– http://www.ihe.net/Resources/index.
cfm#handbook
• The IHE Web site:
– http://www.ihe.net/
Where to find out more
• Integration Statements (surprise! Your
vendors may be here!)
– http://www.ihe.net/Resources/ihe_integra
tion_statements.cfm
• Success stories (read how others
have used IHE successfully)
– http://www.ihe.net/Resources/user_succe
ss_stories.cfm
Conclusion
• Needs in radiology were a
tremendous impetus to develop
and use standards
• Pressure for improved
productivity resulted in an
examination of workflow and the
growth of the IHE efforts
Conclusion
• DICOM and IHE have followed the
principle of specialty independence
• Domain knowledge comes from
specialties
• Technical knowledge comes from the
IT experts on the DICOM and IHE
Committees and Working Groups
• This has been a very productive
partnership
Acknowledgement
• Some of the work reported
(technologist task time) was
supported in part by NIH NCI
Program Project Grant P01CA53141