1. Musgrove Park Hospital, Taunton Dr Paul Burn
Radiology Ordercomms
Musgrove Park Hospital, Taunton
Dr Paul Burn

2. 700 beds 340,000 population served 15 radiologists 2 CT 2 MRI
I work at Musgrove Park Hospital, a medium sized DGH in Somerset with 700 beds, as one of 15 radiologists.

3. 5 Radiology sites 23 Pathology sites 20 years 35 employees
Sheffield based
The ordercomms product we use is called Tquest, made by Indigo4.
Indigo4 are a fairly small company, with 35 employees, based in Sheffield. Although their small size could be seen as a potential commerical risk, they’ve been in involved in healthcare IT solutions for about 20 years. I understand that they are currently have a relationship with 5 Trusts for radiology and 23 Trusts for Pathology.
They’re a great company to work with - the benefits of being able to pick up the phone, talk directly to one of their developers, and get software changes done in a few days, is such a contrast to dealing the larger IT companies.

4. In our trust, Tquest integrates with Cerner, our PAS, CRIS, our radiology information system, and talking point, which we use for voice recognition.

5. Ordercomms Board Radiology Group Ordercomms Team
In terms of organization, we have a Trust ordercomms board, which overseas both radiology and pathology ordercomms for both our hospital and for Yeovil, our sister Trust.
Our department ordercomms group meets once a month, with members of the department, including radiographers and clerical staff, and finally we have a core team.
Ordercomms Team

6. Ordercomms Team Project Manager (25% of time)
PACS Manager (25% of time)
Radiologist Lead (1PA – 4h/week)
This consists of an IT project manager and our PACS manager, both of whom spend about 25% of their time on ordercomms and myself as radiologist lead, for which I get paid 1PA a week.

7. Progress Started >3 years ago from scratch
GP go live rollout
Secondary Care go live - Summer 2011
The project started over 3 years ago and progress has been fairly slow. This has been partly because of various internal political distractions but also because when we started Indigo4 didnt have a mature radiology product – our Trust’s motivation was really focussed around pathology and radiology ordercomms was rather an afterthought. So we’ve spent a lot of time with Indigo4 designing and developing the product.
We went live with GP rollout at the beginning of this year and we intend to move onto to secondary care in the Summer.

8. The Patient
We’ve tried to use ordercomms to improve the experience for all parties in the requesting process.
For patients, to speed up booking, we introduced a call centre, so that instead of posting out appointments, we ask the patient to telephone us to make a booking at their convenience.
To achieve this we needed a mechanism for giving the patient the necessary contact information.

9. Indigo4 achieved this with printing functionality - after the GP or hospital clinician has made the request, a print out is produced which they hand to the patient.
This indicates the name of the test, appropriate background information, including our telephone number and opening times and also any relevant preparation.

10. This is template for an US study requiring a full bladder – the patient is given appropriate drinking instructions.

11. There’s also a bar code, which can be used to identify the patient when they arrive at Xray reception and speed up the booking-in process.

12. The Referrer
For the referrer, the focus of ordercomms is to make it easy to select the appropriate test and minimize the number of button clicks needed to enter additional data.

13. This is the ordering homepage for GPs
This is the ordering homepage for GPs. The statistically most commonly requested tests are listed on the left of screen by modality, these are locally configurable.

14. For more unusual tests, the full menu can be accessed with this button.

15. Where the tests are listed in a hierarchical menu, we call the tree view.
So if you’re looking for XR patella, you drill down through the options, the first column gives the modality…

16. The second column the anatomical region of the body, and finally the required test.
As the screen refresh rate is pretty much instantaneous, it works well.
However what I really would like is my favourites type functionality. So for example, if you’re a wrist surgeon, and MRI wrist is the only test you order, then you need to have that test easily available on the home page, either by creating a my favourites list or by the system automatically remembering your most recent or most frequently chosen items.
Indigo4 recognize that this would be very desirable for clinicians and have said they hope to include it in a future product release.

17. After choosing the test the referrer is confronted by various clerical questions, urgency, transport, request category etc. These are all entirely customizable.

18. We’ve chosen to default tick the straightforward responses, so that assuming the order is routine with no complicating factors…..

19. the referrer can simply press save to complete the order.

20. The Vetter
Vetting requests is a time consuming process and ordercomms has allowed us to streamline our workflow in a couple of ways.

21. Vetting Module Criteria Examination
Patient Type: GP, IP, OP
Age
Sex
Avoid vetting – XR, most US, some oncology CT
Firstly, we can configure the system to automatically triage requests to either those needing vetting or those that do not.
This can be based on the specific examination, the patient type, whether inpatient, outpatient of GP referral, and the patient age and sex.
For example, in our department we intend to avoid vetting plain films, most ultrasound and even followup oncology CT in patients over a certain age (with the knowledge that the radiographer will always provide scrutinize the request at the time of scanning). In this way we can hopefully reduce the overall vetting burden for the department.
Ideally I would like the system to have additional triage criteria, so for example if the referrer indicates that the patient is pregnant, allergic to contrast or in renal failure, then these would override other criteria and ensure that the request is vetted. Hopefully this functionality will come in a future release.

22. If a request is triaged to be vetted, then it arrives in the vetting module, and I think this is one of the best parts of Indigo4 ordercomms.
Each order is listed on the left, along with the time it’s been waiting in the queue, and full details for each order are given on the right, including for contrast exams, the latest creatinine value which is automatically imported.

23. A single click will approve the request and bring up details of the next request in line, so the vetter can rapidly go through a long list of vetting.
This single mouse click compares to 19 clicks when I last counted for vetting in CRIS, I think the new Rowthorne CRIS version requires about 4 clicks per case.

24. Another button will allow the vetter to change or cancel the test or to add vetter comments.

25. In our department, radiographers will have responsibility for all basic vetting and for vetting housekeeping – if a request is complicated or of inpatient status then the radiographer will transfer the request from the general list to the appropriate radiologist’s list.
In this way, each radiologist only has to vet from his own personal list.

26. Requests can also be put on hold, for example if one is waiting for a creatinine result or MRI safety information.

27. And the onhold status is indicated in red.

28. The Imaging Department
In broad terms, the imaging department requires ordercomms to collect lots of useful information from the referrer and present that data in a simple form.

29. urgency/future bookings special needs transport nhs, private pt etc
CLINICAL QUESTIONS
history
pregnancy
allergy
creatinine
MRI safety
CLERICAL QUESTIONS
urgency/future bookings
special needs
transport
nhs, private pt etc
With Indigo4 ordercomms the clerical and clinical questions asked are completely configurable.

30. For example, this is a bowel cleansing declaration we designed
For example, this is a bowel cleansing declaration we designed. The referrer is presented with this when ordering a barium enema or CT colon study, to fulfill national safety requirements.
And this took less than a week for Indigo4 to put this on the system.

31. urgency/future bookings special needs transport nhs, private pt etc
CLINICAL QUESTIONS
history
pregnancy
allergy
creatinine
MRI safety
CLERICAL QUESTIONS
urgency/future bookings
special needs
transport
nhs, private pt etc
Other questions, relating to pregnancy, allergy, creatinine, MRI safety and dexascans area also asked, but only when appropriate to the examination, to avoid irritating the referring clinician. 31

32. urgency/future bookings special needs transport nhs, private pt etc
CLINICAL QUESTIONS
history
pregnancy
allergy
creatinine
MRI safety
CLERICAL QUESTIONS
urgency/future bookings
special needs
transport
nhs, private pt etc
Test specific data can also be associated with a particular exam.
TEST SPECIFIC
INFORMATION 32

33. ‘MRI Liver Cirrhosis’ Booking Information: MR2. 60 min. Gd. Buscopan.
Radiographer Information: L1 Protocol.
For example, in our department, if the clinican chooses the item MRI Liver Cirrhosis, specific booking information will be sent to CRIS with the order, informing the booking staff that the test must be done on our second more up to date scanner, will take a 60 minute time slot, and needs contrast and buscopan injections, and so should be booked during office hours.
The radiographer is also be given the correct scanning protocol.

34. This is a screenshot from our CRIS system.

35. Clinical Information Clerical Information
Of the data sent by ordercomms, I’ve chosen to separate out the clinical information, appropriate for radiologists and radiographers, from the clerical or booking information, so that most of the time staff will only have to look in one of the two boxes.
Clerical Information

36. We’ve also chosen to suppress clerical information from arriving in CRIS if it doesn’t change management, to reduce clutter.
So for example the box shows the GP responses as they appear in CRIS, for a hypothetically complex patient, who requires a future booking date, transport and an emigration xray.

37. The box below shows equivalent data for the same patient when the responses are straightforward, the data is suppressed, reducing clutter and hopefully clerical errors.

38. We have also reduced clutter by suppressing repetition of clerical information sent to CRIS.
This repetition problem arises because CRIS only allows individual exams to be sent from ordercomms. So for example if A&E make a single order of 6 xrays on a trauma patient, these have to be received into CRIS as 6 distinct requests, rather than one combo order or event.

39. So when the order arrives in CRIS, clercial staff have to merge the 6 exams into one event, as shown by the horizontal blue row.
This merging process would result in the clerical ordercomms data being repeated 6 times, cluttering up the screen and potentially leading to errors if one of the exams had unique metadata that was overlooked.

40. To avoid this, Indigo4 have designed clever functionality that suppresses any repetition of non-unique data after merging, so that in CRIS, all the important unique clerical data is presented at the top of the box.

41. Unexpected Problem Demographic mismatches
25% of patients from GP to our RIS
Solution:
alert
additional staff member for ‘housekeeping’
Approximately 25% of requests have some kind of mismatch, either a different name, number or address, or a duplicate entry on PAS. Many of these mismatches caused the orders to be rejected, often without us knowing, which caused problems when the patient called to make an appointment.
Indigo4 have designed functionality to help this process. If a demographic mismatch occurs, an is automatically pinged to a generic address in our department, and the booking team can resolve the issue in Cerner. But this has meant that we need to employ an extra member of staff.

42. Criticisms Style of User Interface – could be improved
No ‘My Favourite Items’ functionality
No Vetting triage for pregnancy/allergy/creatinine
My criticisms of Indigo4 ordercomms are few.
The user interface is very simple and easy to use, but perhaps could be given a make over to improve its visual appeal.
My wish list includes having my favourite items type functionality for referrers and a the ability to automatically triage requests for vetting if the patient’s pregnant, has allergies or renal failure.

43. Summary – Indigo4 Ordercomms
Excellent product and company
So in summary, Indigo4 ordercomms is an excellent product, powerful, flexible yet simple to use and the company is very responsive and pleasant to deal with.