1. Homerton University Hospital NHS Foundation Trust Radiology and EPR at the Brighton Radiology Visit Anant PatelAnant Patel Lead Radiographer (CG/RPS/IT/Redesign)Lead Radiographer (CG/RPS/IT/Redesign) Mohmed PatelMohmed Patel PACS ManagerPACS Manager

2. Homerton University Hospital NHS Foundation Trust Brighton Objectives Visit EPR site with radiology integration (Anant)Visit EPR site with radiology integration (Anant) Radiology Information System (RIS)/PACS & Desk Top Integration (Mohmed)Radiology Information System (RIS)/PACS & Desk Top Integration (Mohmed) Applications integrated to RIS (Mohmed/Anant)Applications integrated to RIS (Mohmed/Anant) Q & As (Anant/Mohmed)Q & As (Anant/Mohmed) ? Anything else (Brighton contingent)? Anything else (Brighton contingent)

3. Homerton University Hospital NHS Foundation Trust EPR at HUH Radiology paperless (Sept 2004) with 2 exceptionsRadiology paperless (Sept 2004) with 2 exceptions 1. Labels (contents)- act as request form 2. External referrals' (GPs/Mental Health) paper requests Radiology film-less (PACS April 2007)Radiology film-less (PACS April 2007) Desk Top Integration (2010)Desk Top Integration (2010)

4. Homerton University Hospital NHS Foundation Trust Contents Radiology involvement with Homerton/Newham ProgrammeRadiology involvement with Homerton/Newham Programme Future FlowsFuture Flows IssuesIssues Other applications it’s integrated/interfaced withOther applications it’s integrated/interfaced with The GoodThe Good

5. Homerton University Hospital NHS Foundation Trust My Involvement with HUH EPR Involved with procurement (1999-2003)Involved with procurement (1999-2003) Radiology System Designer for Homerton and Newham (2003-2004)Radiology System Designer for Homerton and Newham (2003-2004) –Redesign –Design decisions –Additional hardware and software requirements Training (2004)Training (2004) Go Live then troubleshooting (2004-2005)Go Live then troubleshooting (2004-2005) Radiology EPR (2008-)Radiology EPR (2008-)

6. Homerton University Hospital NHS Foundation Trust Why Cerner? Cerner only one with a high level of integration (no maternity though)Cerner only one with a high level of integration (no maternity though) McKesson (Bangkok) only had a few modules that were integrated (Pharmacy/Radiology) with RIS/PACS (Toulouse)McKesson (Bangkok) only had a few modules that were integrated (Pharmacy/Radiology) with RIS/PACS (Toulouse) Siemens no real live system (Sweden), though RIS/PACS at WorcesterSiemens no real live system (Sweden), though RIS/PACS at Worcester System C (Liverpool) too many interfaces and little confidence after demosSystem C (Liverpool) too many interfaces and little confidence after demos Cerner very good at selling from demos, to site visits (Detroit) to HQ environment (Kansas)Cerner very good at selling from demos, to site visits (Detroit) to HQ environment (Kansas) Cerner also able to demo majority of requirements on a live system even if we didn’t understand them fullyCerner also able to demo majority of requirements on a live system even if we didn’t understand them fully

7. Homerton University Hospital NHS Foundation Trust Once Contract Signed.. Current flowsCurrent flows Design Consultancy SessionsDesign Consultancy Sessions QuestionnaireQuestionnaire Future FlowsFuture Flows Making the design decisionsMaking the design decisions

8. Homerton University Hospital NHS Foundation Trust Current Flows Mapped paper flowsMapped paper flows –From requesting to results going to consultant in boxes Needed stronger radiology voice regarding IRMERNeeded stronger radiology voice regarding IRMER –Open requesting policy

9. Homerton University Hospital NHS Foundation Trust Design Consultancy Sessions Sessions organised by Cerner to demo the solution to the system designersSessions organised by Cerner to demo the solution to the system designers Questionnaire provided to draw up future flowsQuestionnaire provided to draw up future flows This is your clinical contract with supplier!This is your clinical contract with supplier!

10. Homerton University Hospital NHS Foundation Trust Questionnaire Contents Order processing (Powerchart etc)Order processing (Powerchart etc) Order Entry FormatsOrder Entry Formats Patient LabelsPatient Labels Cancel examsCancel exams Radiographer infoRadiographer info Radiology ReportRadiology Report Additional InformationAdditional Information

11. Homerton University Hospital NHS Foundation Trust Future Radiology Patient Flows –Four flows Four flowsFour flows Paper GP requests direct access (XR)- Department Order EntryPaper GP requests direct access (XR)- Department Order Entry Paper GP requests schedulable (US)- PM OfficePaper GP requests schedulable (US)- PM Office Direct EPR Referrals (XR, emergency CT, Mobiles etc)- Powerchart/FirstnetDirect EPR Referrals (XR, emergency CT, Mobiles etc)- Powerchart/Firstnet Schedulable requests (CT, MR, US etc)- SchedulingSchedulable requests (CT, MR, US etc)- Scheduling

12. Homerton University Hospital NHS Foundation Trust

13. GP (Paper) Flow- A&C Paper details copied to EPR OrdercommsPaper details copied to EPR Ordercomms –Not scanned, as could be easier for coding Appointments added to electronic wait listAppointments added to electronic wait list –A&C initially schedule –Vetted/justified and rescheduled/cancelled/changed if necessary –Letter to patient Direct Access entered onto OrdercommsDirect Access entered onto Ordercomms Exam to RIS worklist for that dayExam to RIS worklist for that day

14. Homerton University Hospital NHS Foundation Trust OP/IP/A&E (Electronic) Flow Requested electronically (referrers)Requested electronically (referrers) Appointments (A&C staff)Appointments (A&C staff) –Queued then scheduled by A&C staff –Vetted/justified by IRMER pracitioners –OP Letter sent, otherwise IP/A&E verbally notified Direct Access (non-schedulable) straight to RIS Worklist for the dayDirect Access (non-schedulable) straight to RIS Worklist for the day

15. Homerton University Hospital NHS Foundation Trust Scheduling (Electronic) Flow Check in (A&C) patient and ensure correct encounter selectedCheck in (A&C) patient and ensure correct encounter selected –Notification when patients have checked in (status changes from Red to Yellow) Check out (Radiographers) patientsCheck out (Radiographers) patients –Notification from Yellow to Red Correspondence module associated to scheduling difficult to change for specific exams/modalitiesCorrespondence module associated to scheduling difficult to change for specific exams/modalities

16. Homerton University Hospital NHS Foundation Trust Radiographer Flows Check previous examsCheck previous exams Start/complete/vet examStart/complete/vet exam Add image usage/contrast/dose information etcAdd image usage/contrast/dose information etc Ensure data transferred to PACSEnsure data transferred to PACS

17. Homerton University Hospital NHS Foundation Trust Radiologist Flows PACS centric flowPACS centric flow Use templates or VR to dictateUse templates or VR to dictate Sign immediatelySign immediately

18. Homerton University Hospital NHS Foundation Trust Future Hardware Flows PCs at all areas where paper was used (viewing areasPCs at all areas where paper was used (viewing areas Label printers for radiology and pathology (biopsy/drainage procedures)Label printers for radiology and pathology (biopsy/drainage procedures) Voice recognition/digital dictation hardwareVoice recognition/digital dictation hardware

19. Homerton University Hospital NHS Foundation Trust Other Applications linked with Radiology (RIS/PACS) Powerchart (Nurse/Dr Application)Powerchart (Nurse/Dr Application) Firstnet (A&E dept)Firstnet (A&E dept) Scheduling (OPD, Radiology, Theatres)Scheduling (OPD, Radiology, Theatres) PMOffice (PAS)PMOffice (PAS) Surginet (Theatres- not required)Surginet (Theatres- not required) Casenote and Film Tracking (?)Casenote and Film Tracking (?) Winpath (not Pathnet- Pathology)Winpath (not Pathnet- Pathology) Keystone (electronic reports to GP via interface)Keystone (electronic reports to GP via interface) BT/Sectra PACS (via Insignia PACS)BT/Sectra PACS (via Insignia PACS)

20. Homerton University Hospital NHS Foundation Trust PACS-EPR

21. Order Entry Format Design I Which fields needed?Which fields needed? Which fields are mandatory?Which fields are mandatory? Which fields are mandatory in Powerchart (electronic requests)?Which fields are mandatory in Powerchart (electronic requests)? Which fields are mandatory for paper requests Department Order Entry (DOE) ?Which fields are mandatory for paper requests Department Order Entry (DOE) ? Which fields are mandatory in PM Office (paper) and Scheduling (electronic)?Which fields are mandatory in PM Office (paper) and Scheduling (electronic)? See Synergy Article (Patel and Hogg 2009)See Synergy Article (Patel and Hogg 2009)

22. Homerton University Hospital NHS Foundation Trust Issues I- Technical Support (in house very very limited resources)-Support (in house very very limited resources)- –Non clinical –New services – Mammos 4 years to develop –Ca wait data hard to collect from CDS –Updating slow- Mental Health/Podiatry referrers –*Recommend similar model to BT helpdesk* Not full integration between Radiology and SchedulingNot full integration between Radiology and Scheduling –Fields (consultants don’t carry over) –Cancelling scheduled appointments and then the exam Servers overloadedServers overloaded

23. Homerton University Hospital NHS Foundation Trust Issues II- Clinical IRMER-IRMER- –Workaround having schedulable to orders, i.e. vetting –Non Medical Referrers, Open Requesting Policy Delays in lack of desk top integration (clinical risks)Delays in lack of desk top integration (clinical risks) Encounters (patient episodes)- ZZ SectionEncounters (patient episodes)- ZZ Section Clinical details (wrap around text)Clinical details (wrap around text) Obstetric US not integrated (separate system)Obstetric US not integrated (separate system) More Radiology specific code sets (cancel reasons)More Radiology specific code sets (cancel reasons)

24. Homerton University Hospital NHS Foundation Trust Issues III- Multiple Sites Standardisation of flowsStandardisation of flows –Mostly the same –Workarounds when there are not Newham patients coming across to HomertonNewham patients coming across to Homerton –Requires IT admin communication between sites

25. Homerton University Hospital NHS Foundation Trust Issues IV- Targets Ca not identified- still manualCa not identified- still manual Difficult to quickly look at waiting times, need an Information reportDifficult to quickly look at waiting times, need an Information report Information reports needed to be created by IT not RIS manager and dependent on a particular downloadInformation reports needed to be created by IT not RIS manager and dependent on a particular download Current lack of awareness of DSCN 14/2009 and DSCN 18/2009Current lack of awareness of DSCN 14/2009 and DSCN 18/2009

26. Homerton University Hospital NHS Foundation Trust Issues V- PACS via Broker Messages not always going acrossMessages not always going across –Patient merges is intermittent –Minimum updates go across –Messages from DMWL do go across Accession Linking reports not automaticAccession Linking reports not automatic Clinical risks due to lack of DTIClinical risks due to lack of DTI

27. Homerton University Hospital NHS Foundation Trust Issues VI- Misc CommunicationCommunication –Need to test every change to the system even if not directly connected with radiology e.g. new isolation field code set –Paper work immense to get a change, more than BT PACS Downtime/ContingenciesDowntime/Contingencies –Full –Partial

28. Homerton University Hospital NHS Foundation Trust Additional Benefits Incidents- were auditable via PowerchartIncidents- were auditable via Powerchart Incidents- picked up via PACSIncidents- picked up via PACS Privileges for referrers (non medical)Privileges for referrers (non medical) Monitor work from any PCMonitor work from any PC

29. Homerton University Hospital NHS Foundation Trust Good Couldn’t go back to old systemCouldn’t go back to old system Couldn’t go back to paper systemCouldn’t go back to paper system Paperless except labels/consent formsPaperless except labels/consent forms Messaging goes across to PACS most of the timeMessaging goes across to PACS most of the time BT managing PACS, unfortunately not HUH EPRBT managing PACS, unfortunately not HUH EPR Request ‘forms’ can be vetted from anywhereRequest ‘forms’ can be vetted from anywhere Most actions auditable via information dept (from requesting, to rebooking)Most actions auditable via information dept (from requesting, to rebooking)

30. Homerton University Hospital NHS Foundation Trust References Patel, A., and P. Hogg. 2009. Cutting the Paper Chain. Synergy, September 1, 26- 30. http://www.proquest.com/ (accessed November 16, 2010)Patel, A., and P. Hogg. 2009. Cutting the Paper Chain. Synergy, September 1, 26- 30. http://www.proquest.com/ (accessed November 16, 2010)