Radiology Workflows with the Advancement of EHR in Imaging Space
By Doug LaVerdiere

Over the past decade, probably one of the greatest changes in Radiology has been the use of the Picture Archival Communication System (PACS). Most hospitals, imaging centers, and physician practices have taken advantage of PACS to improve the efficiencies and quality of their radiology images. The use of PACS has also made changes to workflows for the technologists and radiologists, some of which are processing film in the dark room to assure the quality of the digital images by reading the images on light boxes and reading images on LCD monitors. With the increasing use of Electronic Health Records (EHRs) by health systems, it might be time to review the workflows used in the imaging space and determine what changes could possibly increase productivity, while creating a more complete health record.

Radiology Information Systems (RIS) have been in use by imaging departments for several decades, but have not been integrated into EHRs very well. Their primary function was used to document exam status (ordered, begun, ended, transcribed, or final), keep track of historical studies, and film room management. Some RIS may also have included the tracking of supplies or additional charges that needed to be sent on to a billing system where there was little clinical documentation collected. A technologist documents clinical findings on paper. That paper is usually passed to the radiologists or scanned into the PACS system for reference for the radiologist. Radiologist’s use of the RIS was limited, if used at all. The radiologist may have searched for historical studies on the patient.

With an EHR today, the ordering physician notes lab and radiology results along with the patient’s problem list, family history, etc. Since lab and radiology results are available to health professionals, a radiology technologist using an EHR can check the patient’s chart prior to their arrival in the department to see if the prerequisite lab test has been completed; validating the results against standard protocol. This saves time and improves patient safety along with the overall patient satisfaction by avoiding the rescheduling of procedures (if necessary testing required by protocol is not complete). Documenting the technologist’s findings pertaining to the contrast, dosage, and injection location, as well as anatomical images indicating areas of interest in the EHR will improve the workflow for the technologist and the radiologist. This will also reduce the use of paper and the potential loss of worksheets in the imaging space.

Today, a radiologist using an integrated EHR can, with a couple of clicks, review the ordering physician’s visit notes, the technologist’s findings, and the patient’s problem list. If the radiologist has any question as to why a test was ordered or needs other relevant clinical information, it is easily and readily available to them. Now, with a patient’s complete record available, the radiologists can better interpret the study images.

There are two workflows used by radiologists in the daily performance of reading images: a PACS driven workflow, or RIS driven workflow. The driver is the work list of exams that need to be read, the order in which they need to be read, and by what criteria. If the site has a PACS driven workflow moving to an RIS driven workflow, one could take advantage of the integrated EHR.

Before we can consider such a change however, the EHR must be able to integrate with your PACS. Many of the EHRs have an Application Program Interface (API) which will launch the imaging study on the PACS monitors once the case has been selected within the EHR.

Changing the radiologist’s workflow from a PACS driven workflow to the EHR will require focus on building the reading work lists. Typically, the work lists on PACS are configured by modality; such as Mammography, CT, MRI, Ultrasound, Nuclear Medicine, and X-ray. Or, the work lists may be configured by radiology sub-specialty; Body, OB, Neurology, Musculoskeletal, General, and Vascular Ultrasound. These work lists also may be configured to place STAT (immediate) cases at the top of the work list, or prioritizing inpatient studies before ambulatory cases. You may find your radiologist wants to build their own work lists, so provide them the tools and guides to create them.

Simply integrating the EHR with PACS images and creating the reading work list on your EHR may not be enough to win over your radiologists to change their workflow. There are other advantages the EHR can offer the radiologists; the ability to protocol procedures, dashboards, unsigned studies, study, and even peer review.

Imaging departments have developed (with the help of their radiologists) a set of common protocols for the MRI and CT studies. They’ve done this so that the proper sequence of scans is provided, allowing the radiologist to interpret the study to give the ordering doctor an accurate, good clinical result. Some EHRs offer a protocol work list which will display the patient and the exam to be performed along with the standard protocol. A radiologist can view a patient on the work list and, based on additional information in the chart, potentially change the standard protocol to more accurately scan the patient.

An imaging dashboard can be helpful to the radiologist to get a quick glance of their work. The dashboard will display the number of cases that need to be read. It may highlight cases that are overdue for reading, STAT and ASAP cases, as well as cases assigned to the physician. This dashboard may also display the number of unsigned cases that the radiologist needs to sign (for the final result go to the ordering physician).

Study and peer review cases can be assigned to a radiologist for a second opinion on a case, or to review cases already finalized. Assigning a case for study review can allow the reviewing radiologist the ability to add his/her opinion to the report, or simply mark the study as “reviewed.” Then the initial radiologist’s report be made final.

With a peer review built into the EHR, the radiologist may not be able to pick and choose the cases they are to review. The peer review would select cases for the radiologist and allow them to mark the case as “agreed” or make comments on where there is disagreement with the original interpretation. The comments are available to the initial reading radiologist and are done anonymously.

Imaging departments with an integrated EHR and PACS can take advantage of many activities that will improve workflow and patient care. Documenting all relevant information by the technologists and radiologist in the EHR can make it possible for any caregiver to find relevant information to care for the patient; the study status can be made available in the patient’s chart and the radiologists can monitor productivity and quality assurance. Each imaging site will have its own unique concerns, but winning over the radiologists who have become comfortable with the tools in a PACS workflow may be your hardest to achieve. But, it can be done; choose a radiologist who is more tech savvy, or one who understand the advantages of an integrated health record and you will have greater success.

If you would like more information about radiology, PACs, or other Epic solutions provided by VCS, please contact us at 610.444.1233, vcs@getvitalized.com, or www.getvitalized.com.