Imaging Exam Acquisition and Quality Control (QC) Workflow in Today’s Consolidated Enterprise – Part 1 of 2

As existing healthcare provider organizations merge and affiliate to create Consolidated Enterprises, image acquisition workflows are often found to be different across the various facilities. Often, the different facilities that comprise the Consolidated Enterprise had different procedures and standard of practice for image acquisition and Quality Control (QC), along with different information and imaging systems.

Standardizing and harmonizing enterprise-wide policies, especially for imaging exam QC, can have significant benefits. A failure to standardize these workflows in a Consolidated Enterprise may result in inconsistent or inaccurate imaging records, which can lead to reading and viewing workflow challenges. These are compounded with a shared imaging system, such as an enterprise PACS or VNA, and can result in delays in care and patient safety risks.

There are generally two areas worth evaluating for optimization:

  • Technologist imaging exam acquisition workflow (Tech Workflow)
  • Imaging record Quality Control workflow (QC Workflow)

Here, we will explore Tech Workflow. QC Workflow will be covered in a subsequent post.

Throughout this discussion the term Radiology Information System (RIS) is used, which can be a standalone system or a module of an EMR.

Tech Workflow

The use of DICOM Modality Worklist (DMWL) for the management of image acquisition is well-understood and broadly adopted. However, the process of marking an exam as “complete” (or “closed”) following acquisition is less standardized and varies across different vendors and healthcare enterprises. The subsequent QC and diagnostic reading workflows rely on the “completion” of the exam before they can begin. For example, an exam that is never marked as “complete” may not appear on a Radiologist Reading Worklist, and an imaging exam that is marked as “complete” when it isn’t will be available for Radiologists to read with only a partial set of images.

Imaging Technologists typically interact with the following applications on a daily-basis.

Tech WF Screens

  • Modality Console – a comprehensive set of tools, attached to the modality, to perform image acquisition activities (such as DMWL queries, exam protocoling, post-processing, etc.).
  • Radiology Information System (RIS) – a specific view into the enterprise RIS application, allowing Technologists to look up patient/procedure information, a set of tools to document the acquisition and mark exam as “complete”, etc.
  • Image Manager/Archive (IM/A) QC – a comprehensive set of imaging exam Quality Control (QC) tools, provided by the Image Manager/Archive (IM/A), such as PACS or VNA, or a dedicated application, to make any necessary corrections to ensure the quality of acquired imaging exam records.

As stated above, there is significant variability among healthcare providers with respect to instituting Tech Workflow policies and procedures. The following diagram illustrates the steps involved in a common Tech Workflow.

Tech WF Flow

Notes:

  • In some cases, Technologists validate the quality of the image and confirm that the number of images in the IM/A is correct for multiple studies at a time instead of each one independently due to the high-volume of exams being acquired.
  • An ability to assess the quality of the imaging exam and correct it (if needed) in a quick and user-friendly manner is critical for an efficient exam completion workflow.

PACS-driven Reading Workflow

In this scenario, the PACS Client provides a Reading Worklist and it is typically responsible for launching (in-context, through a desktop integration) the Report Creator application. There are several methods used across provider organizations to communicate study complete status updates to the PACS.

Method Benefit Challenge
Time out – this is the most typical approach, which considers a study to be complete after a defined period of time has passed (for example, five minutes) since the receipt (by PACS) of the last DICOM object from the modality.
  • Easy to implement
If the time-out is too long, the creation of the corresponding Reading Worklist item will be delayed. Alternatively, a short time-out may result in a Radiologist reporting an incomplete study, which requires follow-up review and potentially an addendum to the report once the missing images are stored to PACS.
HL7 ORM – some organizations release HL7 ORM messages to the Report Creator only after the order status is updated (to study complete) in the RIS.
  • Easy to implement
  • Prevents reporting of incomplete exams (although relies on Technologists to validate the completeness of the study structure in the PACS)
There are scenarios where PACS has received DICOM studies, but their statuses in the RIS application has not yet been updated (for example, as can happen with mobile modalities). The Reading Worklist is unaware of the HL7 message flow between the RIS and the Report Creator and, therefore, allows the Radiologist to start reviewing cases. However, these cases have no corresponding procedure information in the Report Creator. When the Radiologists tries to launch the reporting application in the context of the current study, the Report Creator is unable to comply.
DICOM MPPS – Once an exam is complete, a DICOM MPPS N-Set message (issued by the modality) informs the PACS (and/or RIS) about the structure of the study and the fact that it is completed (along with other useful exam information).
  • Prevents reporting of incomplete exams
  • Automatic confirmation of the structure of the study

 

  • The adoption of DICOM Modality Performed Procedure Step (MPPS) is still limited in most enterprises, even though some modalities, RIS, and PACS support it.
  • Somewhat complex to implement (requires integration and testing between each modality and the MPPS server) coupled with a lack of understanding as to the benefits of this approach in many healthcare provider organizations.
  • Some modality vendors charge an additional fee for a license to enable MPPS integration.
  • Can be disconnected from the “completion” of the exam in RIS (i.e. can ensure the Report Creator’s readiness), provided only the PACS receives and processes the MPPS messages.
DICOM Storage Commitment – Once the exam is complete, a series of DICOM messages (N-Action, N-Event-Report) between modalities and PACS can determine whether a complete study was stored to PACS.
  • Prevents reporting of incomplete exams
  • Automatic confirmation of the structure of the study
  • Although most PACS and many modalities support this DICOM transaction, it is not widely implemented by healthcare providers.
  • Somewhat complex to implement (requires integration and testing between each modality and the PACS server) coupled with a lack of understanding as to the benefits of this approach in many healthcare provider organizations.
  • Can be disconnected from the “completion” of the exam in RIS (i.e. can ensure the Report Creator’s readiness).

RIS-driven Reading Workflow

In this scenario, the RIS provides the Reading Worklist and it is implicitly aware of the status of the exam (assuming the same system is used by Techs and Rads). It creates the worklist item that corresponds to the exam once it reaches the “complete” status. As the Reading Worklist launches both the Report Creator and the Diagnostic Viewer (PACS Client) applications, it does not face the informatics challenges inherent to the PACS-driven Reading Workflow described above.

Enterprise-wide Reading Workflow (Dedicated, Standalone Application)

Some organizations use an enterprise-wide Reading Worklist that is a separate application from the PACS and RIS to orchestrate enterprise-wide diagnostic reading (and other imaging related) tasks across all their Radiologists using fine-grained task-allocation rules. Similar to the RIS-driven Reading Workflow, the worklist launches both the Report Creator and the Diagnostic Viewer applications once a worklist item is selected.

To prevent the complexity of the PACS-driven Reading Workflow described above, some organizations choose to release an HL7 ORM message from the RIS application to the worklist only when the status of the corresponding exam in that system is updated. Alternatively, organizations that choose to send all ORM messages to the worklist application as soon as procedures are scheduled, need to deal with ensuring that the PACS has a complete study prior to allowing it to be reported.

So, what?

It is important for healthcare provider organizations to understand the relationship between the Tech Workflow and the Reading Worklist approach they adopt. If a RIS-driven approach is not chosen, then there should be a clear integration strategy in place to ensure that studies are not reported too soon or missed.

SIIM 2018 Annual Meeting: A Preview

SIIM18 graphic
Gaylord National Resort, National Harbor, MD

The SIIM 2018 Annual Meeting in Washington D.C. is just around the corner (May 31 to June 2). I look forward to seeing many friends, sharing ideas, and learning. I will be involved in number of sessions this year. Here is a preview.

Preparing for a Successful RFP and Contract with Vendors

Thursday, May 31 | 9:45 am – 10:45 am | Annapolis 1

In this roundtable session, participants will discuss how to best prepare for, develop, and issue an RFP, as well as how to analyze and grade the responses. We will also discuss how to best prepare for, and support, contract negotiations with a vendor.

Debate: Enterprise PACS vs. Vendor Neutral Archive (VNA): Choose Wisely

Friday, June 1 | 9:45 am – 10:45 am | Cherry Blossom Ballroom

Depending on your organization’s goals and scale of enterprise, the options available to you for an image archive can vary. In this debate-style session, we will explore the merits of using a Vendor Neutral Archive (VNA) vs. an archive provided as part of an Enterprise PACS. I am moderating the session.

Imaging IT Financials – Learn from the Masters

Saturday, June 2 | 12:45 pm – 2:45 pm | Baltimore 3/4/5

Participants that sign up for this learning lab (limited seats available) will work hands-on with experts to learn how to perform clear and compelling financial analysis. Two lab exercises—one focused on assessing cloud-based vs. on-premises image archive storage, and another on the IT investment required for rolling out the enterprise imaging solution to a newly acquired facility—will be worked on in teams. Each team will share their work with the other near the end of the session. Lab assistants will be on-hand to assist. Participants must bring a laptop or tablet with Microsoft Excel installed.

 

MIIT 2018 – May 4, 2018

In just less than a month from today on Friday May 4, 2018 (Star Wars day!), the annual MIIT (Medical Imaging Informatics and Teleradiology) conference will once again be held at the beautiful Liuna Station in Hamilton, Ontario, Canada.

This year’s theme is Connecting Imaging and Information in the Era of AI and the program features several distinguished speakers from Canada and the U.S.

Talks will cover EMR implementation, Radiology Outreach, the link between Quality and Informatics, Highly Automated Radiology (using AI), an update on IHE, and a comparison of PACS+VNA vs. Regional PACS. It will also have a panel on the impact of EMRs and AI on Radiology and a talk on AI by a speaker from IBM Watson Health.

Register Today!

MIIT Badge

RSNA 2017: PACS Reconstruction

RSNA 2017 Logo

“All the king’s horses and all the king’s men…”

Deconstructing a PACS into discrete, enterprise-scale components seems to be all the rage for many organizations. But, like many things in life, taking something apart is often far easier than putting the pieces back together (and getting something that works).

At this year’s RSNA meeting, I will chair a session on PACS Reconstruction (RCC24) on Mon 27-Nov-2017 from 2:30 to 4:00 pm CT that will focus on the challenges and opportunities of building an integrated enterprise-wide imaging solution for diagnostic review and clinical access.

Following my introduction of core concepts, we will hear from Charlene Tomaselli, Director of Medical Imaging IT at Johns Hopkins and Bob Coleman, Senior Director of Enterprise Imaging Informatics at MaineHealth on their progress and vision to providing an integrated imaging solution for their enterprises.

We will have a panel Q&A with the audience to share lessons learned and discuss how to best prepare for changes.

Enterprise PACS vs. Vendor Neutral Archive (VNA)

I recently contributed an article to HealthCareBusiness that explored the scenarios whereby the use of an Enterprise PACS—defined as a system serving multiple organizations and facilities across an enterprise—or the use of a VNA may be the right approach for an organization seeking to consolidate their image archive and provide a longitudinal patient imaging record. It also covers some scenarios where both may be required.

To some vendors, this can be an ideological debate. It can also lead to discussions about the definition of what is “vendor-neutral” or not.

What is important is understanding what problems you are trying to solve, what requirements exist for the overall solution, what benefits you expect (and a plan to measure them), and having a feasible plan to get there.

SIIM 2017 – Economics of Imaging Informatics

I feel fortunate to chair a very interesting and relevant session during the SIIM 2017 annual meeting this week. The session will focus on the following areas, which are often discussed with clients and industry colleagues.

It seems that there is no well-defined formula or consensus regarding the staffing levels and the structure of an Imaging Informatics Team (IIT). Typical questions are:

  • How large should an IIT be, given the annual Radiology exam volume and number facilities the team supports?
  • In the era of EMRs and IT centralization, what is the right mix of roles between IIT and Corporate IT?
  • How does IT centralization affect IIT financial decision-making and budgets?

James Forrester’s talk will address the above topics, based on his experience at University of Rochester Medical Center.

Another interesting observation is that typically outside of the Director of IIT role, IIT members lack understanding of corporate finance. Even though most significant projects must be budgeted for in advance and any innovation or improvement proposal must be accompanied with a well-crafted business case. Robert (Bob) Coleman’s talk will provide an overview of proven budgeting methods, core components of a good business case, and the required skills to prepare one.

You may also wish to check out this interactive, whiteboard session, which will walk through some common financial models used to evaluate the Total Cost of Ownership (TCO) and Return on Investment (ROI) for imaging IT projects when talking to the CIO.

Looking forward to seeing everybody in Pittsburgh!

SIIM 2017

The Society for Imaging Informatics in Medicine (SIIM) annual meeting will be held on Thu June 1 to Sat June 3, 2017 in Pittsburgh. It has a great program, and by all early accounts, will be one of the best attended in years. See the complete program here. Register to attend here.

Genady and I will be participating.

don-headshot-round

Don K Dennison

Weighing the Options: Enterprise PACS vs. VNA for Enterprise-wide Archiving

Thursday, June 1 | 3:00 pm – 3:30 pm
Science & Innovation Pavilion | Exhibit Hall Theater
#AskIndustry Session

Sharing an imaging archive is generally a good thing, but should you implement one archive and connect multiple PACS and other imaging IT systems to it, or should you build an Enterprise PACS and consolidate your various PACS into it? We will get the perspective of vendor staff that are faced with these types of questions from their customers.

TCB: TCO to the CIO for the CIIP

Friday, June 2 | 8:00 am – 9:30 am
Room 301-302
Whiteboard

The ability of a CIIP to accurately model the Total Cost of Ownership (TCO) for imaging IT application investments and operating costs are critical to getting the support of the CIO, and to getting necessary funding.

In this interactive whiteboard session, “Taking Care of Business: Total Cost of Ownership to the Chief Information Officer for the Certified Imaging Informatics Professional”, attendees will be walked through two scenarios — Multiple PACS Replacement and Consolidation and Cost Model for Shared Enterprise Imaging Platform — by faculty experienced in financial analysis and cost model development.

Combining whiteboard discussion and review of some predefined spreadsheets that provide important calculations for each scenario, this session is intended to be highly interactive with Q&A throughout. The spreadsheets used in the session will be made available to members on the SIIM website following the annual meeting.

genady-headshot-round

Genady Knizhnik

Economics of Imaging Informatics

Friday, June 2 | 4:15 pm – 5:15 pm
Pittsburgh Ballroom B
Core Topic Session

Imaging informatics teams routinely embark on new projects and have to support their operations, which depend on the right budget. Budget preparation and justification skills, as well as understanding of the right size and structure of the operational team, are important for securing required financial support. Attendees will examine the fundamentals of preparing well-defined budget requests that CIOs are looking for, as well as how to structure and staff the optimal imaging informatics team.