2014 Patient-centric Imaging Awards

It’s all about the patient. This is an idea that seems obvious to most at first blush. After all, why would anyone seek a job in healthcare if not to help patients? But sometimes organizations need to rethink their processes to evaluate whether the patient is truly at the center of what they do.

That’s why patient-centered healthcare has become such a focus in healthcare. Within radiology, patient-centeredness is certainly a common rallying cry at educational conferences and is one of the core ideas behind the American College of Radiology’s Imaging 3.0 campaign. It means making sure every scan is appropriate, radiation dose levels are as low as they can be, and that every patient receives their results as quickly as possible.

Last year, we highlighted the work of five organizations who had recently undergone a quality improvement project or upgraded technology that benefited patient care. This year, once again with the help of the ACR, the Health Imaging editorial team selected five sites for their work on improving patient-centered care, whether that meant improving processes in delivering mammography results or leveraging decision support to ensure each scan is appropriate.

Read on to see descriptions of the projects from the stakeholders themselves:

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Cathrine E. Keller, MD.

Same Day Mammography Results: Lake Medical Imaging, Leesburg & The Villages, Fla.

Background: Women undergoing screening or diagnostic mammography await the results anxiously, often suffering a needless delay. We provide same day results to all patients: each women leaves with her lay letter explaining her mammography result, and an appointment for the following year. If the woman needs any additional mammography images or ultrasound, it is performed the same day. If a biopsy is necessary, she has the procedure explained prior to leaving, has an information handout and a contact person’s phone number and for questions. Biopsies are performed within five business days, unless there are extenuating circumstances.

Project: To achieve same day results, we staffed a radiologist in the women’s center reading mammograms contemporaneously. Upon completion of patient intake history and imaging, the gowned patient goes to an exam room. The radiologist reads the mammogram, completes the lay letter, then meets the patient for a breast examination and results. To allow the radiologist to do this, the only other reading responsibilities are the bone films, DEXA, and breast ultrasound and breast MRI.

We revamped the work area and gowned waiting to place the reading room in the midst, with the exam room immediately adjacent to reading room and mammography units across the hall from gowned waiting. We changed procedures with scheduling and the file room to obtain outside prior mammograms before the patient arrives for the appointment in 85 percent of cases.

Results: Using this approach, our satisfaction scores on social media all went to 4.5 /5 or 5/5, and our patient satisfaction surveys went from 4/5 to 5/5.  Referring physician satisfaction rose from 4/5 to 5/5. Our volume of mammography has steadily increased even though nationally there was a dip. Mammography volume increased 7 percent, biopsy volume increased 5 percent, and both breast MR and ultrasound increased proportionately.

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Cloud-Based Imaging: Children’s of Alabama, Birmingham, Ala.

Background: Located in Birmingham, Children’s of Alabama is the third largest pediatric medical facility in the U.S. and the only standalone pediatric hospital and Level I pediatric trauma facility in Alabama. With more than 375 beds, cribs and bassinets, Children’s receives patients from every Alabama county and nearly every state in the nation.

With a large referral network, it was imperative that Children’s physicians were able to quickly and reliably view, share and store the large amount of medical images it received for its patients. However, one of the hospital’s primary referral providers regularly sent CDs that were unreadable or contained corrupt files. This problem wasn’t isolated, either. In fact, 20 percent of CDs were unusable, causing frustration and workflow disruption for physicians, particularly trauma surgeons. In return, when a file was unusable,  young patients would have to be rescanned. These rescans not only cost precious time, but also exposed patients to additional radiation—simply because the original  image could not be read.

At the time, Children’s also did not have 24/7 radiology attending coverage in-house. When an attending was not available at night, and CDs arrived that could not be imported due to compatibility issues or corrupt files, they had to be delivered next door to the University of Alabama at Birmingham. Here they would be read, but patients would be initially receiving a radiology resident’s opinion instead of one from an attending physician.

Project: In early 2012, the hospital began to search for new solutions that would help provide the best care possible. Led by Children’s PACS Administrator, Josh Pavlovec, the Children’s radiology team considered several solutions to solve its medical imaging dilemma, including VPNs, but ultimately decided a cloud-based medical image exchange would expedite workflow, while also providing security and mobile access. Children’s assessed several solutions and selected a vendor in March 2012, which promised to be less “cumbersome” for physicians and referring facilities.

Beginning in September 2012, Children’s introduced the exchange network to its trauma surgeons and emergency room personnel. Word of mouth combined with internal advertising resulted in 500 percent user growth in just two months. The Children’s PACS team quickly rolled out the solution in each department, and today it’s “house-wide.”

Following internal deployment, Children’s began encouraging referring providers to send patient images via the network. Almost all the facilities Children’s reached out to were happy to help by joining the network and sharing images. Initially, Children’s was adding multiple facilities each day to the network. After the majority of in-state providers were on the network, Children’s began connecting with several out-of-state facilities each week—a growth rate it still maintains.

Results: Today, Children’s is connected to 80 hospitals and more than 125 clinics and physicians offices via the network, including large regional providers, rural hospitals, and facilities from as far away as the West Coast.

Less than two years after implementing connected medical imaging services, Children’s has experienced a 60 percent reduction in CDs and a greater lead time in trauma. ER physicians are now able to read images before the patient has arrived via ambulance—expediting treatment.

Pediatric patient outcomes have also improved by expediting the through-put of care, minimizing the need for rescanning and reducing radiation exposure and contrast dosing, which can increase the risks of cancer.

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Radiology Order Entry Clinical Decision Support: Mount Sinai Medical Center, New York City

Background: Radiology orders on inpatients are entered through our EHR. Previously, providers could enter the clinical indication from a structured list or via free text, but there was a desire for clinical decision support at the time of order entry to diminish inappropriate utilization of radiology services.

Project: We deployed a radiology order entry clinical decision support system, targeted at CT and MRI, to implement ACR appropriateness guidelines within our EHR environment. A structured list of “clinical Indications” provided by the decision support system replaced our homegrown list. Providers were presented with this list.

Implementing such a program has several steps.  We are midway through the overall process. The first part of the process involved change management principles.  Along with our EHR team, we educated our provider staff to changes in the Radiology Ordering interface that were needed to implement this system.  We made some modifications to our user interface to address initial concerns. 

For nine months, we ran the system in the background—that is the system provided an appropriateness score of 1-9, 9 being the strongest indication of an exam being appropriate. This was a data collection phase to understand the ordering practices and patterns of our providers.  We did not show the providers the decision support scores during that phase.

Results: We learned that on a weekly basis, approximately 10 percent the exams ordered received a low score between 1-3. Just over 2 months ago, we turned on display of the decision support score, showing providers the score when it is between 1-4 and suggesting alternative exams through the automated interface. We are just beginning to analyze the data to look for change in ordering patterns.        

We have anecdotal comments that this has been helpful. After 4 to 6 months, we will analyze the data to determine if there is a change in overall performance with regard to utilization. We also will implement an education program directed at providers who consistently order exams identified as inappropriate in the CDS system.  This is intended as a quality improvement program to be conducted in a positive, collaborative, non-punitive environment.

We have been early adapters of the decision support system. It is our belief that this is an important tool in getting the patient the correct exam. This will assist in diminishing inappropriate exams thereby reducing patient radiation exposure and simultaneously controlling costs.

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Lowering Dose in Fluoroscopically-guided Interventional Procedures: Mayo Clinic, Scottsdale, Ariz.

Background: Multiple organizations, from the ACR to the Joint Commission and Society of Interventional Radiology, have guidelines about recording patient dose and provide educational content for ALARA (As Low As Reasonably Achievable) programs. However, operators of interventional fluoroscopy systems often lack the means for incorporating these principles to routinely reduce patient skin dose.

Mayo Clinic Scottsdale found the two components of a dose lowering program to be standardized, low dose X-ray system settings and the consistent practice of dose lowering principles by operators.

Project: To improve consistency in this area, Mayo Clinic Scottsdale used phantom tests and protocol review to establish optimal X-ray system settings, and developed informatics tools to identify user behavioral factors associated with elevated patient radiation skin exposures.

X-ray system protocols were systematically reviewed, with a goal of eliminating variability and standardizing low dose protocols with physician staff agreement for all equipment. Phantom tests evaluated dose for fluoroscopy and digital subtraction angiography (DSA) using iodine-based contrast-to-noise ratio (CNR) values and the effects of added Cu filtration to lower dose.

Detailed patient reports were created from three interventional fluoroscopy systems having DICOM Radiation Dose Structured Reporting. Technical settings prescribed during a procedure were highlighted if they were related to behavioral choices of X-ray prescriptions. Automated reports were then generated that provided summary and physician specific patient skin dose values.

  • Eight key metrics were captured and made available for every procedure. Physicians can lower patient skin dose by:
  • Positioning the patient’s skin further from the X-ray source than the Interventional Reference Point (IRP)
  • Consistent placement of detector as close to the patient as possible
  • Consistent use of minimum rate (pulse/sec) for both fluoroscopy and acquisitions (DSA)
  • Use of Tap and Pause behaviors for both fluoroscopy and DSA
  • Use of collimation rather than magnification
  • Use of reduced magnification
  • Use of fluoroscopy save rather than DSA or Digital Spot, if possible
  • Use of 0.1mm Cu minimum filtration for all protocols

Results: A 60 percent overall reduction in mean skin exposure was reported in a 12-month period following the implementation of the program. Also, procedures resulting in peak skin dose greater than 5Gy were dramatically reduced, from approximately 14 out of 1,000 events, to one out of 1,000 events, during the 12 months following implementation.

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Bridging the Gap: Implementing an Imaging: West Virginia University Hospitals, Morgantown, W.V. Network in Appalachia

Background: West Virginia University Hospitals (WVUH) is a 531-bed tertiary care teaching hospital that includes Ruby Memorial Hospital, WVU Children’s Hospital, WVU Stroke Center, and the Jon Michael Moore Trauma Center—the state’s only American College of Surgeons nationally-verified Level 1 trauma center. As a large healthcare system in rural Appalachia, we serve as a tertiary referral center for West Virginia as well as portions of Maryland, Ohio and Pennsylvania.

WVUH radiologists and technologists identified a recurring situation in which patients with urgent or emergent medical and surgical problems were referred to our center from other institutions after having initial diagnostic imaging at an outside facility. Often, these patients arrived without the imaging study or report. In some cases, patients arrived at our facility with images on compact discs. However, the discs were often misplaced or were in the possession of one physician, making it difficult for additional medical teams to review the images. Many of these patients required repeat imaging at the expense of unnecessary radiation exposure, financial resources, and most importantly, invaluable time. There was an apparent need for a central repository for these images to improve the efficiency of patient care.

Project: To alleviate this problem, in early 2011 WVUH initiated installation of a web-based viewer on clinical computers throughout the hospital. The software is a multimodality image archive which allows the upload of compact discs or other digital format diagnostic imaging files from various centers to a single repository. The system has familiar controls, allowing users to easily navigate the images, regardless of the source of the image.

Over the next few months, physicians within many departments at our hospital requested access to this software in order to coordinate care with physicians from referring institutions. As popularity continued to grow at WVUH, outside facilities also began joining the network. Over the short time period of approximately 18 months, an additional 31 facilities joined. For outside facilities, the process to join the network is simple and cost-free, requiring only an internet connection and a virtual private network (VPN) connection.

Results: We have analyzed multiple parameters regarding the usage of the viewing software at these institutions. The data demonstrates rapid, continuous growth in the number of institutions using the network, the frequency of its use, and the number of examinations uploaded to the server. For example, the application was launched 10,214 times from January through March 2013, compared to only 4,862 times from July through September 2011.

The network has revolutionized care at our tertiary referral center. The rapid expansion of the network speaks for its success. We have significantly reduced unnecessary repeat imaging, which is particularly important in our pediatric population. In cases of trauma or medical emergencies, surgeons can review images for pre-operative planning before the patient even arrives at our facility. Physicians at multiple institutions can discuss cases with one another within seconds of uploading images to the server. In a short period of time, a large network has been created in a rural setting, where previously no such system existed. Establishment of this network affords the timely, coordinated actions of multiple healthcare institutions, improving the efficiency of patient care, dramatically reducing radiation exposure, and in cases of time-sensitive emergencies, saving lives.