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 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. 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 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 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 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 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 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 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) 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) 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 (tape- based) –Digital dictation (digital voice files) Both involve a person transcribing the report into the RIS Dictation/transcription system –Conventional dictation (tape- based) –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 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. 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 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 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 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 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 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) 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 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) 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 Registration Orders Placed Orders Filled Film Folder Image Manager & Archive Film Lightbox report Report Repository Diagnostic Workstation Modality acquisition in-progress acquisition completed images printed Acquisition Modality

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 PACS- based environment with an RIS, but no interface between the systems: request to report ; 32 steps Eliot Siegel: in a film-based environment with no PACS or RIS: request to report ; 59 steps Our study (ultrasound): in a PACS- based environment with an RIS, but no interface between the systems: request to report ; 32 steps

What standards have helped radiology? Imaging equipment Other devices (storage, etc.) Interface

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 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 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 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 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 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 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 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 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 In HL7 specifies Actors for: –ADT/Patient registration –Order Placer –Order Filler –Image Manager Plus the transactions to support these

Scheduled Workflow Profile Registration Orders Placed Orders Filled Film Folder Image Manager & Archive Film Lightbox report Report Repository Diagnostic Workstation Modality acquisition in-progress acquisition completed images printed Acquisition Modality

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 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 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! 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 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 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) 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) 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) 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 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 Users Handbook (a must!): – cfm#handbook The IHE Web site: – The IHE Radiology Users Handbook (a must!): – cfm#handbook The IHE Web site: –

Where to find out more Integration Statements (surprise! Your vendors may be here!) – tion_statements.cfm Success stories (read how others have used IHE successfully) – ss_stories.cfm Integration Statements (surprise! Your vendors may be here!) – tion_statements.cfm Success stories (read how others have used IHE successfully) – 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 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 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 P01- CA53141