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For other articles and previous issues click here. August 22, 2005 Making
Workflow Work PACS brings workflow changes. Here’s advice on how to make those changes successful when your department goes digital. Installing a PACS—whether in a hospital or stand-alone imaging center—brings many changes, most notably in workflow. “Everything changes from the time the referring physician even thinks about ordering an imaging study until the patient walks out with his completed exam,” says Edward C. Heere, president and CEO of PACS developer CoActiv Medical Business Solutions in Ridgefield, Conn. Some people along the workflow chain will see more changes than others, but the result is typically more productivity and accuracy for everyone. “You have to understand that speed is important because as health insurance continually reduces what radiologists get paid to read exams,” Heere says, “the pressure is on to read more and more cases in a shorter amount of time.” Among those who will see the largest number of changes are those who work in the film room. They will no longer be needed to archive newly acquired film images. However, they’ll likely have new tasks such as burning CDs that can be given to physicians and patients and helping staff navigate the PACS system. “Are you going to free up some film people? You might over a period of time,” Heere says. “But PACS definitely reduces a lot of the work in the film room and thus you don’t need as many people.” Often, Heere says, film room people can be retrained to be part of a help desk. “All attending and referring physicians are now using a system that is new to them, and they need someone to answer their questions. So what you can do is retrain the film room people to become PACS superusers and have them take the first call coming in. If it’s something they can’t handle, then you go to the PACS administrator, and if he [or she] can’t, you refer it to the support team of the PACS company.” Mostly Filmless Laws require that all medical records be kept for a number of years. The laws vary not only from state to state but also among facility types (for example, hospital vs. imaging center) and patient groups (for example, minors vs. adults), Heere notes. There always will be some physicians who refuse to use the new technology. “They’ve been looking at film for 50 years and they want to continue to hang it up on the wall and look at it,” Heere says. Sometimes, too, surgeons prefer to view films hanging next to them in the operating room (OR). “It’s more convenient to have the film on display next to them than having to look at a monitor depending on where it is in the OR,” Heere explains. While film room employees will still handle some traditional tasks, more of their responsibilities and workload will change as more and more images can be stored and retrieved via the PACS. Administrative Changes With PACS, the patient’s demographic information—name, birth date, referring doctor, procedure, etc—is automatically transferred from a HIS/RIS to the modality via a DICOM modality worklist. A DICOM worklist eliminates the need to reenter data at every step along the way. “Thus it helps avoids time-consuming data entry errors and improves overall productivity,” Heere says. “Scheduling is simplified because you entered the information once into the RIS, and it gives the information—via the DICOM modality worklist—to the modality and ultimately to the PACS,” adds Heere. “Billing is simplified because the information is more accurate and it is passed right through and becomes part of the information stream,” Heere continues. “The coding section, which is very, very critical and traditionally has taken a lot of manpower, can now be streamlined, too. These are all workflow changes.” Heere notes that the new technology makes order entry a key point. “The information entered has to be accurate because it is only entered once,” he says. For safety reasons, though, it still has to be checked and confirmed several times along the way. “You always have to make sure you’re doing the right study on the right person.” Technologist Changes In a film world, the technologist takes films and runs them through the processor. The tech must then make sure the films are OK before releasing the patient. In a digital world, that’s not an issue. The technologist can move from one case to the next after completing each study because the images are instantly available. “It makes him or her tremendously more productive,” Heere says. Some facilities are finding they can hire “tech aides,” who will take patients from the waiting room to the changing room and explain the procedure they are about to undergo. It’s a cost-saving measure, Heere says, because the tech aides don’t require the same education and training as the technologists and are not paid as much. The technologist doesn’t have to bring the patient from the waiting area and wait for him or her to change, which makes it possible to do more studies in the same time. Physician Changes In a film world, the radiologists see what studies they have to read when the film jackets pile up on their desks or someone walks in with an emergency study. Different PACS/RIS systems offer different features for creating computerized worklists from which radiologists manage the studies they have to read. “Very often there are choices,” Heere
says. “Worklists can be created in different ways and the
physicians have to say, ‘I want it to come this way or I want
it to come that way.’” In some arrangements, physicians must log on to the system and search for and pull referred cases. In other systems, the cases are automatically routed to them and a pop-up tells them they have studies to view. Inside and Outside Radiology “Reducing manual data entry, paperwork, and the number of manual processes required to fulfill and document the order are critical,” Norder says. “But just as critical is the need to incorporate individual physician’s preferences for viewing the studies in specific software applications, and the need to ensure that the dictation and transcription workflow improves, too.” Norder notes that physicians often have individual preferences based on the way they have been doing their work, and it can take some negotiating among the members of the practice to determine which method is best for everyone. Another workflow change: physicians no longer have to be physically at the site where the study was acquired to read the images. “They can work from any location that has a diagnostic workstation and connectivity to the information systems; the studies will be routed to them wherever they are,” Norder says. “If they are at a remote hospital and have nothing to read from that facility, cases from other hospitals or imaging centers can be pushed to them for review, thus eliminating down time.” Heere says his company’s PACS has a unique feature—physicians can send any colleague who is on the system an automated referral. “Say the referring doctor looks at an imaging study and decides he wants the cardiologist to take a look at it, too. He right clicks on the exam and it brings up the names of all the doctors he can send it to. He finds the cardiologist’s name, hits a button, and sends that exam to him with a request for a referral. As soon as he sends it, a message pops up on the cardiologist’s screen telling him that new referral has arrived.” With such a system, secretaries no longer have to call the specialist’s office to arrange a referral. Nor do they have to arrange for couriers to mail or hand-deliver the film to the appropriate specialist. Clearly, one of the major benefits of RIS/PACS integration, Norder says, is the ability to reduce the amount of time it takes to route studies to radiologists for their impressions and return that information to the ordering physician. “For rural hospitals that don’t have dedicated radiologists, after-hour and weekend reads were problematic before PACS, especially in emergency situations. In many cases, emergency department physicians need a preliminary impression fast, and their ability to push studies to a radiologist in a different city certainly improves patient care.” Patient Changes Many PACS vendors and consultants advocate mapping the department’s workflow before installation to help determine what key changes in responsibilities will be necessary. “We speak with the key staff members in the workflow chain, from those who enter the information at the front end to the technologist who completes the study to the radiologist who reads it, to the transcriptionist who types the impression,” Norder says. Norder believes people adapt to change faster if they are included in the change process and trained along the way. “We regularly see variations in the way people perform the same fundamental tasks, some of which are not obvious at first glance,” he says. “Including staff in the change process ensures that critical workflow steps are identified and retained after the PACS goes live.” Don’t Overplan If you attempt to do it all up front, he says, “you are not going to get it right anyway. You really have to put it in and see how your people react to it.” Bob Wisniewski, BS, RT, senior applications analyst in radiology informatics and PACS administrator for Northwest Community Hospital in Arlington Heights, Ill., says most people are resistant to change. He found that when his department converted to PACS in 2003, it helped to present the workflow changes to the staff as pros and cons. “You might tell the technologist the con is that after doing things the same way for 25 years you have to learn new equipment. You have to learn to use a DICOM worklist,” Wisniewski says. “But there are more pros than cons. The pros are you’re going to be more efficient. You won’t have to type patient information in the system, you don’t have to go into the darkroom, and you can spend more time with the patients.” Another pro, he says, is that you will have to repeat fewer studies because the radiologist can tweak the digital images to see what he or she needs. “You still need to do good positioning, you still have to do quality assurance and verify the exam, but with the ability to tweak the images at the workstation you may not have to do a repeat,” says Wisniewski. He also advises bringing the technologists into the loop early on how their workflow will change. “The PACS systems that are out there are real easy for technologists to learn and they need to feel a part of it,” he says. He found that most people, after they get over their initial resistance to change, embrace PACS. “They will see the light,” Wisniewski says. “People we thought we’d have to drag along with us kicking and screaming are saying, ‘I don’t ever want to go back to film.’” Heere agrees: “I have never heard of any PACS users ever wishing that they had film back.” — Beth W. Orenstein of Northampton, Pa., is a regular contributor to Radiology Today. |
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