As communication across a healthcare system becomes more sophisticated, traditional imaging workflows must evolve. Optimizing enterprise imaging depends on leveraging the right technology—whether those tools come from a vendor or are developed in-house—and requires the coordination of stakeholders at every level. And what managing workflow across several healthcare systems?

Take it from the top

When thinking about imaging workflow, it’s important to start at the beginning and not forget about optimizing the process for ordering physicians, suggests Peter Sachs, MD, associate professor of radiology-diagnostics at the University of Colorado School of Medicine in Aurora. “In addition to the patients being our customers, obviously they are too,” he says.

Order entry has huge downstream implications for the rest of the workflow, and the process should be as efficient as possible. It is a challenge in the current environment not to overload clinicians with too many clicks before a study can be ordered. At the same time, useful information must be translated to the radiologists down the line. Sachs says this will be made simpler with embedded clinical decision support, which providers will be mandated to use by 2017 thanks to a provision in the most recent Medicare sustainable growth rate patch.

Another focus area for optimizing workflow is the protocoling process. It helps to have all relevant information automatically pulled from the EHR or imaging order so that radiologists have it right in front of them, however, vendor-supplied solutions could be more sophisticated in this area, says Sachs. “It’s a long way from where it needs to be.”

Currently, patient-specific and imaging test-specific information that’s pulled to protocoling and interpretation screens is fairly generic. Sachs offers the example of a chest CT for interstitial lung disease. In such cases, it would be incredibly helpful for diagnosis-specific information like pulmonary function tests to be automatically pulled by the system.

DIY tools

To fill in the gaps of needed features, organizations may need to develop their own tools to improve workflow in the EHR and RIS. Not only can such tools improve efficiency, by developing them in-house, sites can often save money and wind up with a custom solution tailored specifically for their workflow. Sachs says his institution has developed a number of homegrown programs, including:

A tool for clarifying what lines and tubes are being used on ICU patients. With one button, information from nursing sheets about lines and tubes can be pulled to the radiologist’s reading palette

Workflows to handle protocoling and ordering of interventional radiology studies

A workflow to assist clinical research coordinators, since trials have very specific requirements for interpretation and billing

An electronic protocoling process for CT, MRI and nuclear medicine studies. “One of the problems with generic solutions is they don’t necessarily take into account a place’s specific workflow,” says Sachs. “So we had to build ours to account for our particular way of doing scheduling and preauthorization.”

Optimizing imaging workflow extends beyond just completing an interpretation; it also includes coordinating with other specialties. Informatics experts at the University of California, Los Angeles (UCLA), have been working on development of RadPath, a web-based application to integrate radiology and pathology reports.

“We started building RadPath as a way to clarify diagnostic findings between radiology and pathology for downstream users,” says Corey Arnold, PhD, assistant professor in the UCLA Department of Radiological Sciences and member of the UCLA Medical Imaging Informatics group.

Because radiology and pathology routinely report in separate silos, there is the potential for confusion in diagnosis. This can take time away from downstream users like primary care physicians and even result in missed cancers or other misdiagnoses.

Arnold says RadPath allows for integrated diagnoses, automatically merging relevant information from both radiology and pathology into a single report. The project, which has been in development for about two years, is currently focused on the domain of lung cancer, but will look to expand to other disease areas such as prostate and brain cancers.

Radiologists have the challenging task of interpreting images that cannot fully represent underlying pathophysiology. Differential diagnoses can help to narrow suspicions, but pathology, with the benefit of actually testing the suspected cells, can be more definitive. In some cases, radiology and pathology can conflict.

In these cases, it could be useful to have a report that integrates and highlights findings from radiology and pathology so all information is available in one place to downstream users, says Arnold. “After a lot of conversation, we started thinking that maybe we should go a step beyond that and get a radiologist back in the loop after pathology to correlate their findings with the pathology results.”

With RadPath, after a pathologist gives a diagnosis, he or she initiates creation of the integrated report. RadPath automatically pulls information such as diagnosis and key images from the pathology report and sends it to the radiologist, who adds correlative information. The radiologist can agree or defer to pathology results and add additional data. For example, in some cases the radiologist can add context by describing primary and secondary cancers. And if there’s a situation where a radiologist is highly confident a mass is malignant, but the pathology results came back benign, the radiologist could determine the mass was not adequately characterized during sampling and indicate a re-biopsy may be necessary.

The group is testing RadPath now and getting feedback from downstream users such as surgeons and oncologists who receive the compendium RadPath report featuring key images from radiology and pathology along with integrated information. Initial observations suggest that the process is fairly quick for users, adding just over two minutes to the radiologist’s workflow and about 90 seconds for the pathologist.

Arnold says the next step is to measure the clinical impact of RadPath. In addition to including other disease areas, the team also will be looking to add new features like expanding the sources of data.

Widening the scope—the multi-enterprise environment

As if optimizing imaging workflow across a single enterprise wasn’t challenging enough, there may come a day when implementing a single workflow across a multi-enterprise environment becomes more common. And that day may not be too far off.

Gary Wendt, MD, MBA, professor of radiology, enterprise director of medical imaging and vice chair of informatics at the University of Wisconsin-Madison, spoke on the topic of multi-enterprise workflow at RSNA 2013. His environment encompasses more than 10 distinct legal entities throughout southern Wisconsin, all using a single PACS workflow. While Wendt says this environment is unique today, that may change.

“As accountable care takes hold more, the necessity to actually have multiple organizations group themselves together is going to be more important,” he says.

There are two major factors to consider when attempting to implement a single workflow across multiple enterprises, according to Wendt. First, the PACS must accommodate multiple RIS/EMR contexts with separate medical record numbers and leverage a master patient index so patients can be linked appropriately. Most PACS currently don’t accommodate multiple medical record numbers.

Even if the PACS can handle multiple medical record numbers, they don’t all present patients in a single, unified view. This is the other major hurdle, as patients can move freely between organizations and receive imaging studies from each. If one patient is treated as multiple individuals by the PACS, exams will not be displayed side-by-side and instead necessitate flipping between “patients” in the system to see all images.

Tackling this Herculean effort to integrate enterprises is not without its rewards, of course. Moving patients without an effective way for images to follow them can result in repeat exams, which is neither time efficient nor beneficial to the patient.

“If you can have a common group of radiologists that’s reading level 1 trauma centers, outpatient clinics, HMOs, and rural hospitals, you can load balance and make the most efficient use of radiology resources,” says Wendt.

Helping hands

As usual, technology looms large when coordinating an enterprise workflow, but partnerships with other stakeholders are what truly make optimization possible. The Society for Imaging Informatics in Medicine has an EHR user group that facilitates the sharing of user-built workflow tools.

Within any organization, many different stakeholders can offer their own unique perspective on what needs to happen to streamline imaging workflow. The key is to build an effective team that can bring those viewpoints together. Sachs notes: “It’s absolutely critical to have a team that involves technical, administrative and clinical stakeholders to get this done.” HI