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.

Article – MU No More…Meet MACRA, MIPS and APMs

The death of Meaningful Use (MU) will not be mourned by many physicians.

While the overall program drove adoption of electronic medical record (EMR) systems, which is necessary for information accessibility, the measures required to be reported upon were viewed by many as misguided and not a reflection of the actual practice of medicine.

Also, many of the EMR systems implemented were criticized as being hard to use with limited capabilities to allow information interoperability with other systems.

Regardless of one’s views of MU, CMS is moving on.

With a keen focus on patient outcomes, CMS is looking to new models for reimbursement, such as the Medicare Access and CHIP Reauthorization Act (MACRA) legislation, introduced last year.

CMS is also intent on addressing the lack of interoperable patient record information.

“We’re deadly serious about interoperability. Technology companies that look for ways to practice data blocking in opposition to new regulations will find that it will not be tolerated.”

Andy Slavitt, acting administrator of the Centers for Medicare & Medicaid Services

The MACRA site provides an overview of Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs), which are sure to be popular acronyms to fill the void created by the decline of the use of MU in discussions.

Here is another article on Slavitt’s comments. And another article by HIMSS.

My previous posts on healthcare payment reform are herehere and here.

Article: Major Insurance Company will no longer cover Breast Tomosynthesis Exams

Per this article, citing lack of clinical evidence and radiation dose concerns, Cigna will no longer cover Breast Tomosynthesis exams, which generate 3D image sets, as of 15-Feb-2016.

Digital Breast Tomosynthesis (DBT) exams are often praised for their superior ability to provide effective imaging when diagnosing women with dense breasts.

Somewhat of a challenge for IT systems and staff due to the significant size of their data sets compared to the traditional 2D mammogram exams, adoption of DBT modalities has been rapid lately due to the generally accepted diagnostic benefits.

I can’t imagine that this lack of coverage will last.

For those wanting a description of the different between 2D (Mammogram) and 3D (Tomosynthesis) breast imaging, this article provides an overview in plain language.

Here is an RSNA article on the state-of-the-art for Breast Tomosynthesis.

And here is an article on the merits of Breast Tomosynthesis over traditional Mammography for detecting cancer.

And another on reducing recall rates.

ACR: CMS Delays Clinical Decision Support (CDS) Implementation Requirement

ACR post (30-Oct-2015) is here.

Highlight…

…CMS states that they anticipate including further discussion and adopting policies regarding claims-based reporting requirements in the CY 2017 and CY 2018 rulemaking cycles. Therefore, they do not intend to require that ordering professionals meet this requirement by January 1, 2017

Article – First Look at Stage 3: CMS Sticks to Its Guns on APIs, Patient Engagement

Here is a good summary on what is new in Meaningful Use Stage 3 Rules.

This excerpt caught my eye:

As far as timing goes, CMS said it disagrees that the API functionality cannot be implemented successfully by 2018 “as the technology is already in widespread use in other industries and API functions already exist in the health IT industry.”

All of this should be a boon for the FHIR (Fast Healthcare Interoperability Resources) standard development community and the Argonaut Project, working on API-related standards, as well as for the broader community of mobile app and personal health record developers. With barriers to patient access to their data coming down, patients will finally be able to create their own portals, separate from any health system and share that data with whomever they want.

This is good news for everyone.

If we truly want so solve issues that require access to information where and how we need it, we must provide interoperability. This means not only the data needs to available be in a format that is understood and supported by common applications, it means the method of discovering and accessing that data needs to be understood and supported, as well.

FHIR® (clinical data) is built on the right web technologies and design methods, as is DICOMweb™ (imaging data). With these APIs, we can discover and access the necessary patient information and make it available in any care setting we need.

And these APIs will create the foundation of data liquidity to spark an explosion of innovation of applications—including traditional departmental and enterprise ones, but also web and mobile ones.

Without clearly defined, supported and accessible APIs, we (healthcare) had no hope of achieving the kind of system-wide change required. We have no more excuses now.

Article – The Healing Power of Your Own Medical Records

This NYT article tells the story of a very bright young man that took control over has health data and probably saved his own life. Few of us have the knowledge to do what he did, but most would agree that having the choice to access our health data is the right approach.

I suspect that as long as the risk of uninformed patients misusing the information they access and the risk of unauthorized access of protected health information outweigh the demand for access to the information, progress will be limited. How do we balance freedom of information and data liquidity with effective access controls and reasonable assignment of liability?

Previously, I blogged about my thoughts on patient privacy and its use as an excuse for an non-interoperable patient record.