PACS: Enhancing Radiology Workflow - Integrating PACs is key.
* This is a re-print of my article that ran in rt-image, vol. 21, no. 35 in Sept. 2008*
PACS is ubiquitous. At one time or another, whether attending the Society for Imaging Informatics in Medicine (SIIM) conference, researching the latest technologies in imaging informatics or evaluating PACS vendors, we have all heard statements to that effect.
That means a second round of PACS implementation – consisting of ripping out the old and putting in the new – is underway. There can be many different reasons why an organization may have lost faith in its initial PACS vendor – perhaps for not providing adequate support, having annual costs that are too high or not improving their software in the direction that is needed.
Or, maybe a vendor’s product does not fit into an organization’s workflow. That is a surprising reason, but it is occurring to some users. During early implementations of PACS, the goal was to get images stored into PACS without much thought given to the other work that occurred in obtaining the images.
For your next PACS implementation, be sure to fix your workflow woes by making sure that you understand how to better integrate PACS into your imaging department’s workflow.
Looking at Workflow Nuances
Before discussing the integration of PACS and radiology workflow, a review of imaging workflow basics is necessary. In its simplest form, the workflow consists of: order entry; receiving the patient; imaging; evaluating the images; releasing the patient; submitting the images for interpretation; interpreting the images (dictation); transcription of the report; and, finally, signing the report.
These steps seem pretty unremarkable until you analyze the nuances that occur at the transitions of each phase. It is at the transition points in the imaging phases that imaging informatics can really make an improvement in the overall workflow.
And, in the interpretation process, technology can make enormous improvements during those transition phases and the actual interpretation process itself. Extra efforts should be undertaken to ensure complete documentation of existing workflows from the very beginning of the imaging process (order entry) through the signing of the final report. Only then should the project to go from analog to digital workflow begin.
Early Oversights
One of the primary things that PACS vendors failed to provide in the early versions of their systems was the inclusion of functionality allowing the integration of the radiology workflow nuances into the PACS workflow. In its standard form, PACS vendors simply allowed studies to be in one of two statuses – unread studies and read studies.
The basic PACS workflow was to image a patient, send the studies to PACS in an unread status, and have the radiologists interpret the study, changing the study to a read status. All the other workflow that occurred in radiology never changed.
Orders were provided via written scripts and entered into a hospital information system/radiology information system (HIS/RIS). This generated the printing of a paper requisition that served as a transportation slip, patient identifier, a tickler indicating a study needed to be performed, and, ultimately, a document handed to the radiologist stating that a study was ready to be read.
Properly Integrated PACS
Now, having a fresh picture in your mind of how radiology workflow used to occur (or still does for those who didn’t integrate it properly), and understanding the various areas in which a study progresses through its lifespan, taking the paper out of the workflow and moving into the “Digital Era” should become more clear.
Here is a scenario with a properly integrated PACS:
That means a second round of PACS implementation – consisting of ripping out the old and putting in the new – is underway. There can be many different reasons why an organization may have lost faith in its initial PACS vendor – perhaps for not providing adequate support, having annual costs that are too high or not improving their software in the direction that is needed.
Or, maybe a vendor’s product does not fit into an organization’s workflow. That is a surprising reason, but it is occurring to some users. During early implementations of PACS, the goal was to get images stored into PACS without much thought given to the other work that occurred in obtaining the images.
For your next PACS implementation, be sure to fix your workflow woes by making sure that you understand how to better integrate PACS into your imaging department’s workflow.
Looking at Workflow Nuances
Before discussing the integration of PACS and radiology workflow, a review of imaging workflow basics is necessary. In its simplest form, the workflow consists of: order entry; receiving the patient; imaging; evaluating the images; releasing the patient; submitting the images for interpretation; interpreting the images (dictation); transcription of the report; and, finally, signing the report.
These steps seem pretty unremarkable until you analyze the nuances that occur at the transitions of each phase. It is at the transition points in the imaging phases that imaging informatics can really make an improvement in the overall workflow.
And, in the interpretation process, technology can make enormous improvements during those transition phases and the actual interpretation process itself. Extra efforts should be undertaken to ensure complete documentation of existing workflows from the very beginning of the imaging process (order entry) through the signing of the final report. Only then should the project to go from analog to digital workflow begin.
Early Oversights
One of the primary things that PACS vendors failed to provide in the early versions of their systems was the inclusion of functionality allowing the integration of the radiology workflow nuances into the PACS workflow. In its standard form, PACS vendors simply allowed studies to be in one of two statuses – unread studies and read studies.
The basic PACS workflow was to image a patient, send the studies to PACS in an unread status, and have the radiologists interpret the study, changing the study to a read status. All the other workflow that occurred in radiology never changed.
Orders were provided via written scripts and entered into a hospital information system/radiology information system (HIS/RIS). This generated the printing of a paper requisition that served as a transportation slip, patient identifier, a tickler indicating a study needed to be performed, and, ultimately, a document handed to the radiologist stating that a study was ready to be read.
Properly Integrated PACS
Now, having a fresh picture in your mind of how radiology workflow used to occur (or still does for those who didn’t integrate it properly), and understanding the various areas in which a study progresses through its lifespan, taking the paper out of the workflow and moving into the “Digital Era” should become more clear.
Here is a scenario with a properly integrated PACS:
- Study is ordered and the patient is processed into the department.
- After arrival is completed electronically, the technologist, viewing a RIS-based work list, sees that order appear on the screen.
- The technologist can then optionally print out a small card for use in transporting of this particular study to be performed on an inpatient. If the patient is an emergency department patient or an outpatient, the technologist can simply call the patient back into the imaging room.
- The technologist finds a study to be performed on the imaging device modality worklist, selects the correct patient from the list, and begins the imaging exam. If this is a completely integrated system, the initiation of a study on the imaging device would change the order’s status in the RIS to a “begin procedure” or “start procedure”.
- Imaging performed in the study is sent to PACS. Once the images arrive in PACS, they would be in a “performed” status.
- The technologist then moves to a PACS workstation, finds that particular study on the worklist (set to display only studies that have not been marked as reviewed), and opens it up for viewing. While the study is opened, the technologist will review each image in the study, ensuring it is in the proper sequence, as an appropriate window/level, and is of overall diagnostic quality.
- While the study is opened, the technologist can scan any paper documents developed during the study (contrast questionnaires, etc.) and provide the radiologist with pertinent patient history through the use of a “study notes” type of tool.
- After assuring the study is diagnostic, scanning in paper documents, and providing study notes, the technologist then changes the study from a “performed” status to a “reviewed” status. This equates to the technologist handing the radiologist a piece of paper saying that the study is ready for interpretation. The study is no longer visible on the technologist’s PACS worklist (which was set to show only performed studies) and appears on a radiologist’s worklist (which is set to show only reviewed studies).
- The radiologist opens the study for interpretation, and, through properly deployed hanging protocols, views not only the images of the study but is automatically presented with the patient history and any scanned documents.
- Through the use of voice recognition technology, the radiologist begins a dictation session from within the open study. After the interpretation, the radiologist either reviews and signs the report immediately (placing the study into a “reported” status), or sends the report to a transcription for verification (placing a study into a “dictated” status). Within a short period of time, the review process is completed, and the report is sent back to the radiologist for signing, at which time the radiologist will verify the reports and sign it, thus placing the study into a “reported” status.
Easier Said Than Done
Now, while it is very easy to document such a system on paper, correct implementation is a completely different matter. Obviously, there are multiple components that need to be put into place to allow such a tight integration. Migration to a workflow such as the one listed above cannot happen solely upon the purchase of a PACS.
An appropriately functioning HIS/RIS, voice-recognition dictation, and document scanning solution all must be part of the implementation. If you have members of your project team who balk at higher prices that come with this functionality, it is important to be sure to explain to them how this is needed to improve overall workflow.
After reviewing the 10 steps listed above, I hope that it is easier to realize that simply allowing a study to be marked as “read or unread” does not fit the bill anymore. Vendors have to work toward providing a PACS solution that fits the needs of the radiology department.
Since the first generation of mainstream PACS 10 years ago, some vendors have realized the need to provide a multiple-step process for radiology studies in their PACS. However, whenever I visit SIIM or Radiological Society of North America and ask a new vendor if they provide multiple types of statuses for radiology studies, they still respond (with a curious look on their face), “Well, of course we do. Look here. See? ‘Read’ and ‘unread’.”
I try to explain why I look for more than just two statuses; but if, after the first iteration of what I just described above, I still get a blank stare, you can bet the conversation is pretty much over.
Points to Ponder
Through this article, I hope to have accomplished two things. First, I hope I have effectively put into print what many PACS administrators have been trying to convey to vendors over the past two years which is, “Please build us a system that can adapt to what we do.”
Secondly, I hope I conveyed to PACS administrators, radiology managers, and IT directors how important it is to find a vendor whose system can provide all these finer points of functionality.
It is definitely worth the extra money to purchase this upfront.
It will save you time, effort, and even more money when you can start seeing a return on investment more quickly and prevents you from having to rework your PACS and radiology workflow two years after your initial purchase. If you don't properly integrate your workflow upfront, I will put my money on the fact that you will probably be reevaluating PACS vendors within three years.
More discussion on this topic can be found on my PACS administrator discussion forum at: http://www.jspacs.com. For information beneficial to new or even seasoned PACS administrators, visit http://www.pacs-admin.com.
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