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November 28, 2005

Piecing Together Filmless Workflow
By Larry Palazzolo
Radiology Today
Vol. 6 No. 24 P. 28

Cincinnati Children’s Hospital Medical Center developed its own system to manage the rest of the information needed to make the jump from digital images to true digital workflow.

If you were to imagine an ideal information management system for a radiology department, it would probably include the following:

• An integrated system that saves radiologists time and stress, enables dynamic workload balancing across the department, automatically prioritizes the sickest patients, supports decentralized, paperless workflow, enhances communication within and beyond the department, and documents conveyance of radiology report findings.

• A system that speeds care, improves access to critical information, and decreases interruptions.

You may think you were dreaming if you heard a radiologist say, “My workflow is so much more efficient that now I can read more cases.” That dream is becoming a reality due to a new clinical radiology informatics system developed and launched at Cincinnati Children’s Hospital Medical Center (CCHMC) in collaboration with the University of Cincinnati’s College of Business.

“A couple of years ago, we realized that our radiologists didn’t always know which case to read first,” says lead developer, Mark Halsted, MD, cochief of the CCHMC Radiology Informatics Core Research. “We read a high volume of ‘STAT’ cases, and we kept getting calls asking us to look at specific cases next. These calls interrupted our workflow just when we needed to be most efficient. We knew we could do better. We could limit interruptions, improve patient care, and decrease staff stress, all at the same time.” The system took approximately three years to build from the ground up but has seen its greatest evolution in the past 12 months.

Launched on July 18 at CCHMC, the Automated Radiology Triage System (ARTS) leverages an integrated RIS/PACS and voice recognition (VR) to close the loop on true filmless, paperless radiologist workflow.

Evolution of ARTS
Managing workflow, delegating tasks, and brokering clear, informative communication are all key to running any successful department in any business. The same thought process was used in the development of ARTS. “We acquire and read studies at satellites in multiple locations,” Halsted says. “One site might be busy while another might not be. We knew we could do a better job of load-balancing in real time while getting reports out to our referring clinicians immediately, but to do this, we needed a way to improve communication.”

The beta version of ARTS started off as a triage system and evolved into a departmentwide communication and documentation tool. It also offers improved communication beyond radiology and permanently documents conveyance of critical reports. Radiologists can be at multiple workstations anywhere in the world and access the system, which provides a filtered, dynamic work list so they can always read the highest-priority case, from both operations and illness acuity standpoints.

The latest version of ARTS was developed while measuring every important step in workflow to increase efficiency in patient care. In collaboration with faculty from the University of Cincinnati’s College of Business (who were involved in building the automated prioritization algorithm for the system), the team started with an idea of how to prioritize patients and ended up with a system that became the paperless departmentwide solution for CCHMC.

What Is STAT?
STAT is an overused term which for ordering physicians means anything from “multiple trauma” to “I want this report soon.” This overuse has made the significance of the term less clear on a case-by-case basis. “Many busy radiology practices will have so many STAT exams in the queue that you don’t know which case should be top priority,” Halsted says. “Our system addresses a lot of workflow issues that we believe aren’t adequately addressed by existing filmless radiology systems.”

According to Halsted, “The threshold as to when a case is read should be determined by the acuity of the case, not how busy I am.” ARTS gathers all the hospital, radiology, and technologist information in one place before the images ever reach the radiologist.

Radiology department workflow is generally first come, first served. This can cause a workflow bottleneck for the rest of the hospital, and may not reflect workflow elsewhere in the hospital such as in the emergency department where triage cases are based on medical acuity. “We in radiology needed to improve our approach to the triage issue,” Halsted says. “Simply designating cases STAT and non-STAT didn’t give us enough information to know which study to read next.”

Workflow Efficiency
The idea that radiologists are not always sitting side by side but may in fact be across town, the country, or the world is a cornerstone of ARTS. ARTS sorts and distributes cases, while allowing radiologists to communicate electronically, so radiologists are not stepping on each other’s toes.

The priority of each case is determined by a combination of variables incorporated into an algorithm in ARTS. Technologists are trained to enter the acuity scores consistently. The algorithm then factors medical acuity, operations information, and timing of entry for each case, as well as whether patients are waiting for results, to prioritize cases.

The algorithm was developed from a combination of variables from 500 fictitious patient histories. CCHMC asked 20 radiologists to evaluate 25 patient histories each and rank each patient’s severity, looking for interobserver and intraobserver variability. The University of Cincinnati’s College of Business then took all the survey results and generated a mathematical algorithm. Once that was completed, they took a 10-patient sample and ranked the severity of the illness/injury of these patients using the computer algorithm, comparing it with the prioritizations made by five of the most internally consistent and experienced radiologists in the group. The R-value of the variability between the algorithm and radiologists was 0.89, 1.0 being perfect. “Given the inherent subjectivity of prioritizing some cases, we don’t think any human could have done better at ranking patients exactly as a group of radiologists would have,” Halsted says.

The word STAT, however, is not completely exiled in the CCHMC radiology department. It is just reserved for those cases that are truly high priority. “The algorithm is tuned to ensure that we meet our one hour report guarantee for every ‘STAT’ exam,” Halsted says. CCHMC also offers their patients the option of waiting in the waiting room for results, so they can seek treatment immediately if, for instance, a fracture is diagnosed. If they choose to wait, the system appropriately increases their priority in the queue.

According to Halsted, there are several ways in which ARTS goes beyond previous filmless efforts. First, it is a communication tool. It frees radiologists from spending the time they would otherwise have to use to locate referring physicians to clarify histories, convey results, or notify them of unexpected findings and automatically routes such communication through hospital operators and clerical staff. This allows radiologists to focus on personal communications with select physicians in cases where it is truly needed, increasing the quality of communication between radiologists and referring sources, while decreasing the overall amount of time on the telephone. This makes radiologists more efficient and increases the number of studies they can read in one day.

Making Filmless Paperless
Second, it is a documentation tool. Every communication of an important finding to a clinician or one of their staff is permanently documented in the system. This is the case whether the radiologist conveys the result, or whether the report is conveyed by a clerical staff member or hospital operator. In the past, some of these communications were not documented. The new system fills that gap.

The system also records preliminary interpretations, subsequent versions of reports, and addenda. This is a very useful feature in a training institution, where clinical decisions may be made based on residents’ preliminary reports that are later changed upon staff review. Additionally, it encourages good relations with referring departments.

Patient prioritization is a third major feature. Currently, even filmless systems that sort by STAT status do not discriminate among studies ordered STAT. This is unrealistic because many clinicians have learned that they can get the results more quickly if they order exams STAT. As a result, this designation has become overused, and therefore less meaningful. Unfortunately, patient care can suffer as a result. When confronted with a stack of STAT requisitions, the radiologist has no way of knowing which are truly emergency cases and which are not. ARTS solves this issue by prioritizing cases by medical acuity.

Decentralized workflow support is a fourth major feature. The system allows a group of radiologists to read exams acquired from multiple workstations located anywhere. While this is a theoretic advantage of PACS, realistically it has not been clearly addressed. ARTS coordinates decentralized workflow involving multiple sites and multiple radiologists while prioritizing patients in work lists that can be changed flexibly in real time based on dynamic workflow volumes. It does this while showing all users, at any point in workflow, case “ownership” by any radiologist or technologist. This transparency prevents staff from duplicating efforts.

ARTS also supports decentralized communications. Rather than occupying prime clinical space, groups of hospital operators could be located anywhere with coordination of all communications provided by ARTS.

Workload balancing is a fifth major feature. Services can be set up to accommodate the scheduling and coverage needs of any particular department. ARTS allows radiologists to cover one or more services dynamically so procedures can be performed and conferences can be led by radiology staff while coverage is efficiently provided by other staff. Despite shifting such coverage duties on the fly, patient care proceeds seamlessly. “If one of our radiologists located at a satellite clinic is called away for a procedure,” Halsted says, “any of our other radiologists can watch the uncovered service with a mouse click. The system then prioritizes all cases being watched by the covering radiologist, and selects the most urgent case from all services that the radiologist is covering. If some of those cases require reports to be called, the system automatically routes the reports to the operators for conveyance to the clinicians. The covering radiologist does not need to change his or her workflow, and simply continues to dictate each next case in the queue.” The system handles each case automatically from there.

Working paperless gives ARTS the edge. “We still do have one piece of paper involved at the initial order entry level,” Halsted says. “When an electronic order is placed by a physician, it is electronically routed to radiology and printed out. Simultaneously, ARTS gathers contact information, history, and exam information electronically and automatically. The technologist simply acquires the studies digitally and populates the acuity information in ARTS with a few mouse clicks. If there are technologist comments such as ‘pain is located at base of thumb,’ ARTS provides a text field for the technologist to enter those. These comments are then displayed to the radiologist interpreting the case. Once the images are digitally acquired, the paper gets shredded, and there is no more paper associated with that case in radiology. This saves the technologists’ time because it cuts out the faxing and hand carrying of forms to radiologists. The radiologist’s workflow is entirely paperless.”

State-of-the-art, integrated RIS/PACS/VR should theoretically create a very tight system. However, the team at CCHMC saw room for improvement. “As users, we felt we were in a unique position to recognize and fix persistent workflow issues,” Halsted says.

Bringing ARTS to Market
ARTS is currently a Web-based application. The system continually runs queries to keep updated with the RIS. At CCMHC, ARTS runs parallel to RIS/PACS/VR. “What we did was to improve on a state-of-the-art, single vendor integrated RIS/PACS/VR,” Halsted says, “by developing new software which could run either in parallel with or integrated into such a system. We thereby solved workflow problems that persisted even after our state-of-the-art system was up and running.” For ARTS to become more widely available, a vendor would need to market it to hospitals. The medical center is currently exploring possible vendor options.

An added benefit of ARTS is that it leverages the theoretic promise of speech recognition to make radiologists’ workflow more efficient. This benefits radiologists directly and has helped voice recognition gain acceptance among radiologists at CCHMC. With VR, reports are available immediately for communication to the referring physician, but in many practices, there is no good mechanism for immediately conveying the report to the ordering clinician. “Before ARTS, we faxed each report out to the clinician’s office as soon as it was signed, and we still do that today,” Halsted says. “But many physicians who need certain results as soon as possible aren’t sitting by their fax machines. That’s when we’ve had to use the phone.” Now, ARTS brokers direct telephone communication with referring physicians automatically without routinely involving radiologists or breaking their workflow. “We still value personal conversations about complex cases, but when a report is as simple as ‘Left upper lobe pneumonia,’ our referring physicians are happy with a phone call from an operator telling them that—and they realize that they save time by not demanding that the operators track us down personally to convey each routine finding to them,” Halsted says. “So we’ve selectively cut out the tedious phone calls while making the complex ones more efficient.” VR makes it possible, but ARTS puts it into practice.

People Issues
The biggest challenge in getting ARTS to work in real practice relates to human behavior, not technology. “When we launched ARTS, the department needed to determine which radiologist covered which services at which times of day,” Halsted says. “Although we thought we already had that worked out, it turned out that there were many different opinions about how the work should be distributed. Once implemented, ARTS made minor misunderstandings transparent. In launching ARTS in a new department, trying to get the humans to agree as to how workflow ought to be will prove more difficult than the technological issues in using the system. Also, it will be important that all radiology employees are on the same page, working together to improve patient care. ARTS provides the tools to enable them to make that happen.”

ARTS is now in clinical use, driving workflow at CCHMC. The system maximizes the RIS/PACS/VR investment by enabling radiologists to work more efficiently and with fewer interruptions while providing load-balanced, decentralized, paperless workflow, improved communications, and documentation of critical communication events. CCHMC and the University of Cincinnati’s College of Business, as part of their research collaboration, are now measuring the clinical impact of ARTS on clinical operations, patient satisfaction, and radiology staff stress and job satisfaction. “It’s one thing to build and launch a system and then claim that it improves patient care,” Halsted says. “We believe that ARTS really does improve patient care and are studying its impact in an objective, scientific way.”

— Larry Palazzolo is freelance writer based in Philadelphia.

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