Transcript Digital photo test slides

Practical guide: Medical Imaging
Concepts
Clinical and workflow
Steven Horii, MD, FACR, FSIIM
Professor of Radiology,
Clinical Director , Medical
Informatics Group
Modality Chief, Ultrasound
Hospital of the University of Pennsylvania
Attending Radiologist, Children’s
Hospital of Philadelphia
Disclosures
• My wife is a full-time employee of
Cerner Corporation
• Site PI, Phase III clinical trial,
ultrasound contrast for liver masses,
Bracco Pharmaceuticals, Inc.
• Expert witness, Blakely Sokoloff Taylor
& Zafman, LLP (Patent litigation)
Introduction
• A tiny bit about clinical stuff
• The unavoidability of workflow
• The complexity of workflow and
multiplication of that through
interacting (or colliding) workflows
• The changing healthcare model
• What that means for you
Clinical
• What we do
• What do you mean “we”, kemosabe?
• OK, then – what do physicians in
general do; with some radiology
particulars
Workflow
• How we do it
• In twenty minutes?
• OK, then –
– Why workflow can seem simple
– Why it generally is not
– Why is workflow important?
Clinical: An overview
• Physicians:
– Given a story or complaint by a patient,
– Try to figure out what, if anything, is wrong
– Figure out a treatment plan
– Treat the patient
– If the patient is not improving, return to
bullet item 2
– Oh yeah, get paid
Clinical: An overview
See patient
Figure out
what is wrong
No
Treat patient
Getting
better?
Yes
Submit bill
Next
Notice anything?
• From a description of what we do, a
flow diagram (of sorts) comes out
• It is difficult to separate what we do
from how we do it
What do radiologists do?
• Image humans (and animals) to:
– Diagnose diseases or anomalies
– Guide and perform procedures
– Help develop treatment plans
– Evaluate progression or regression of
disease (response to treatment)
– Assist in forensic investigations
Imaging
• Mechanical energy (ultrasound)
• Electromagnetic energy
– RF (MR imaging)
– Infrared (thermal)
– Visible light (endoscopy, ophthalmology,
dermatology)
– Ultraviolet (fluorescence microscopy)
– Gamma (radiographic imaging)
– Protons (radiation therapy)
Adult liver
A 50 year old man with cirrhosis and worsening LFTs
Adult liver: good news for this
patient
This is color flow and power Doppler: it shows that the blood
vessels in the liver are not distorted by any “mass”.
Obstetrical ultrasound
How we do it: Workflow
• I recommend review of the IHE Profiles
for radiology if you are not already
familiar with them
• The profiles were developed largely
through detailed examination of
radiology workflow
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
Why are healthcare workflows so
complex?
•
•
•
•
Legacy procedures and systems
We are idiosyncratic (Paul Chang)
Interactions between departments
Many personnel, each with particular
tasks to perform and information
needed
Complex workflow: intraoperative
ultrasound
• We provide ultrasound in the operating
room to assist the surgeons in locating
structures and planning surgical
approaches
• About 20% of the time, the ultrasound
changes the surgical plan
Display during intraoperative
scanning
With permisson: Susan Rowling, MD, Frank Spitz, MD
Display: the radiologist’s view
Intraoperative ultrasound example
A 41 year-old woman with colon carcinoma for resection ofa solitary liver mass
The mass looks more like normal
liver after compression
This is NOT another metastasis – it is an hemangioma;
a benign liver lesion.
Intraoperative ultrasound
• Often resulted in delays for both
surgery and radiology
• Surgeons had to wait for 20 minutes or
more for us to arrive with our
equipment
• For radiology, it added to patient
waiting time (took a radiologist and
sonographer out of the Department)
Basic workflow: Intraoperative
liver
Delays
• We noted that some intraoperative
ultrasound studies were subject to
much greater delays than others
• We thought that one difference was
whether or not the study was
scheduled in advance
• We looked at the difference in workflow
The non-scheduled workflow
addition
The non-scheduled workflow
addition
• Included more steps
• Each step involved time
• Once we showed how many more steps
were involved, we discussed this with
the surgeons and explained that
scheduling ahead of time would result
in shorter delays
• They now routinely schedule their
studies
Intraoperative ultrasound
• Illustrates that an already complex
workflow in radiology,
• Is made more complex when it involves
interaction with another department’s
workflow
• Note that this does not even include the
workflow steps done by surgery
Intraoperative ultrasound
• Also shows the need for
standardization in the OR (hence the
DICOM in Surgery WG)
• There are vendor-based standards, but
they are usually proprietary
• There are standards (HDMI for video)
that permit display on different devices,
but not integration/interoperation
Why is this stuff important for
you?
• Much of radiology workflow grew out of
the film, paper, and pencil age
• This includes not only processes, but
organization
• Radiology had been largely radiologycentric
– This in a time when “patient centered” has
become a goal
Opportunities
• Our workflow tends to be supported by
thick client, customized software
• It is neither agile nor adaptable
• The rapid changes in healthcare have
meant much more difficult transitions
for our legacy information systems
Big changes are coming
• Remember the bit about “getting
paid”?
• Much of our (meaning healthcare in
general) workflow is based on a fee for
service model
• The service-oriented specialties
(radiology and pathology in particular)
are effectively piece workers
The approach to reducing
healthcare costs
• The US Government has, in response
to escalating healthcare costs,
attempted to fix this by reducing
payments to hospitals and physicians
• What is the logical response to reduced
reimbursement per procedure?
• Why, perform more procedures, of
course!
The newer model for
reimbursement
• Accountable care
• Reimbursement is based on outcomes,
cost reductions, and appropriateness
rather than just what was done
• How can radiology prepare for this?
• It is why you are (or should be) hearing
about quality measures, appropriateness
criteria, and meaningful use
Examples
• CPOE – show that use improves
appropriate requesting of imaging
studies
• ACR Imaging 3.0
• The Leapfrog Group - founded by large
purchasers of healthcare services,
mostly large corporations
Importance for you (us)
• We need to be agile and adaptable
enough to provide the informatics and
information technology resources to
support changes in the way healthcare
is practiced and reimbursed
The emphasis
• The emphasis will be (and is) on:
– Rapid data mining
– Increased patient involvement
– Improved communication between
healthcare providers
– Demonstrating improvements in outcome
– Proving increased efficiency
Think about how these things can
be accomplished
• Do you want to continue to write
monolithic thick client applications with
numerous customizations?
• And then have to debug, support, and
update them?
• This meeting gives me hope that there
is a better way and you folks are
practicing it