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.

 

IHE Integration Profile Development – Vote Now (Voting Closed)

Update: Voting is now closed. Integration Profiles selected by the IHE committees for development in the 2016/2017 development cycle:

  1. Enterprise Scanner Protocol Management
  2. Critical Finding Follow-up and Communication
  3. Standardized Operational Log of Events

What healthcare use cases do you want addressed? What are the biggest interoperability issues facing our community today?

Provide your input to the IHE integration development process by completing the survey. Simply rank the six proposed profiles. It take 10 seconds.

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 – 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.

Article – Imaging Shift to Hospital Outpatient Facilities Concerns Radiologists

Following my post on consumer choice in imaging services, in which I asked how do we use quality—and not just cost—to help consumers make choices, I found some observations in this article on the shift of imaging being done in imaging centers to outpatient facilities to be quite interesting.

For example…

“groups at imaging centers may struggle to upgrade or get new equipment, which could affect image quality and interpretation”

So, how do I, as an imaging consumer know which provider has modern, safe, calibrated equipment, operated by qualified and skilled operators when making my choice of where to get imaging done?

I don’t ask my dry cleaner about what equipment they use, or when it was last serviced, or how much experience the person in the back doing the work has. Nor to I ask these questions about my car wash.

I often make choices in dry cleaning and cash washing based on cost, but more so convenience.

But this is my health and it is my body going through that device, not my clothes or my car.

I wonder how many people will simply trust that a friendly receptionist, flowers and nice magazines in the waiting room at a facility near where I work means quality and safe imaging. If I have a good experience during my imaging appointment, but they miss important findings due to low quality images (or lack of sub-specialty knowledge/training), how will I know?

Unlike a spot that doesn’t come out of my shirt or a still dirty section of my car, the consequences can be severe.