Workflow may tame outside imaging beast
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Interpretation of outside imaging exams poses significant challenges in tertiary care trauma centers. A formal workflow process can help radiology departments better handle these requests, and deliver additional benefits such as reduced radiation exposure, accelerated patient care and increased throughput, according to an article in the August issue of the Journal of the American College of Radiology.

Stephen P. Reis, MD, from the department of radiology at Westchester Medical Center in Valhalla, N.Y., and colleagues identified the increasing numbers of requests to interpret outside imaging exams. Westchester Medical reported a 1,400 percent annual increase in requests for interpretation of outside imaging studies from 2010 to 2011.

Although providing interpretation of outside exams can help reduce unnecessary repeat exams, the process presents several problems. Reis and colleagues identified six problems and shared their department’s workflow solution.
  1. Radiology departments must decide how outside images will be uploaded. Westchester Medical uses software that enables upload of DICOM images by technologists and radiology information management system (RIMS) staff, which minimizes technical complexities of image upload. RIMS staff provides oversight to avoid medical record or study accession number conflicts.
  2. There are no best practices for storage of outside images. Although some sites use cloud-based systems, Westchester installed a regional PACS server. This allows outside centers to download images, and bypasses the image upload challenge in some cases. It also provides faster access at a one-time, rather than per-study, cost, according to the authors.
  3. Referring physicians need to designate which studies should be available for comparison and which should be interpreted. Westchester developed a standard form with clear guidelines for physicians.
  4. Radiology residents who provide preliminary interpretations of outside exams, in some cases without oversight by attending radiologists, violate Accreditation Council for Graduate Medical Education rules. The Westchester system treats outside exams like CT studies, with residents providing preliminary interpretations via a PACS note, which is reviewed by an attending physician. Attending physicians also are available for consult 24/7 via PACS workstations.
  5. Images acquired at outside institutions may use different protocols and imaging parameters, which may result in variable image quality. Reis et al “set a relatively low bar for deeming outside studies nondiagnostic.” The department leaves this determination to the interpreting radiologist, and has provided a standard disclaimer to attach to the request.
  6. Medicare does not reimburse for interpretation of outside studies, and these requests require physicians to reallocate time that could be used to interpret studies acquired at their own institutions. Westchester radiologists receive relative value unit credit for interpretation of outside exams.
As radiology departments increasingly stress value and customer service, this approach may offer a new model. “[We] hope this will provide value-added service for our referring physicians while decreasing radiation dose to their patients,” concluded Reis and colleagues.