Radiology's Best-kept Secret: RIS-driven PACS Workflow

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Children’s Hospital of Alabama in Birmingham deployed PACS four years ago in crisis mode. Prior to PACS implementation, within a few months, the radiology department had lost three of its eight radiologists. “We had to become more efficient,” recalls Radiologist in Chief Stuart Royal, MD. In a way, however, the crisis proved to be serendipitous. The radiology department had considered investing in PACS technology earlier, but had delayed deployment because early systems did not facilitate RIS/PACS integration—a criterion considered essential to success by the hospital radiology department. “The department realized PACS integration could increase productivity among radiologists and improve workflow across the facility,” says Lynne Hamer, divisional director, pediatric imaging.

As the downsized department surveyed the PACS landscape in 2002, it realized that at least one current system delivered true integration. The hospital decided to deploy the Siemens PACS, RIS and Web based image and report distribution in an integrated “RIS drives PACS” workflow model.

The hospital PACS went live in April 2003. Since the deployment, the imaging department has converted nearly all imaging equipment to digital, installing CR and DR in the diagnostic, outpatient radiology and emergency departments. Operating rooms are outfitted with digital C-arms. Other digital modalities include a 16 and 64-slice CT, ultrasound, echocardiography and two 1.5T MRI systems.

Outside the walls of radiology, Children’s Hospital deployed PACS in the emergency department, operating rooms, hospital clinics and all nursing floors. “Acceptance of PACS has been phenomenal. Our physicians and staff have embraced the technology… It is the single most positive change I have seen in imaging over the past 20 years,” reports Hamer.

“It was a lifesaver,” adds Royal. “We could do the work of eight radiologists with five.” Royal credits the department’s success to RIS/PACS integration and RIS-driven workflow. Today, the hospital stands at the cutting-edge of pediatric patient care. Its eight-person radiology department completes 101,000-plus procedures annually. It is 99 percent digital, except for scoliosis film.

Since deploying RIS/PACS, Children’s Hospital has realized a number of benefits including improved and accelerated patient care, cost savings and reduced report turnaround time. In fact, Royal estimates that the move to the integrated Siemens RIS/PACS model has yielded a 40 percent increase in radiologist efficiency.

Dissecting RIS-driven workflow

The Children’s Hospital radiology department implemented integrated workflow when it deployed PACS. Under the Children’s model, the hospital information system (HIS) updates patient information in the RIS,  called syngo Workflow. Data flow is seamless for radiologists. “Everything is in one place. They don’t need to move from one system to another to complete their work,” explains PACS Administrator Lynn Odom.

The integrated model provides the robust flexibility needed in the pediatric environment. Take for example MRI studies. In the adult world, radiologists don’t view images until after the exam is complete. But in the pediatric environment, radiologists typically want to view images as they are acquired. That’s because pediatric patients often require sedation prior to an MRI study. “We need to minimize the time patients are sedated and maximize the information acquired during the study,” says Royal. The integrated RIS/PACS allows radiologists to view studies in progress, so if a patient requires an additional sequence it can be completed during the initial study.

The RIS/PACS integration boosts patient care in other ways as well. For example, Children’s Hospital strives to provide one-stop shopping. As the only children’s hospital in the state, it isn’t uncommon for its patients to travel half a day or longer for medical testing. In addition, anxious parents want same-day results.

“We try to give [outpatient] families preliminary results before they leave the hospital,” says Royal. This model requires a robust electronic system that includes a sound archive, rapid access to prior studies and a solid means of distributing images to clinicians. Integrated RIS/PACS provides a complete solution. Radiologists can readily view studies on the PACS workstations, and its archive provides rapid access to priors. Specialists, such as neurosurgeons and orthopedic surgeons, can view studies via the Web-based Viewer and provide diagnostic input. The rapid and enterprise availability of images allows physicians to provide same-day preliminary results in many cases.

The benefits of the Web-based Viewer travel in all directions. For example, in complicated ER or ICU cases, physicians and radiologists frequently confer by phone. With Web-based Viewer, all involved physicians can look at the images simultaneously and consult, whether they are located in the radiology department, ICU, OR, emergency department or at home. “It’s virtually a real-time experience between the radiologists and the referring clinicians that facilitates accurate and quick care,” explains Royal. 

Enterprise web-based 3D further multiples these benefits. “My philosophy is to make images and reports available to everyone [involved in patient care],” says Royal. The Web-based Viewer with web-based 3D distributes essential imaging data throughout the enterprise, and Siemens thin-client 3D allows any user with internet access to complete reconstructions of CT data. “There are relationships among structures that can’t be seen very well with standard axial imaging. Thin-client 3D brings this capability to clinicians like neurosurgeons and orthopedic surgeons,” explains Royal.

Children’s Hospital further extended workflow benefits by investing in Siemens digital radiography (DR) systems. The investment has reinvented workflow in the hospital’s busy orthopedic clinic, which sees up to 100 patients daily. Prior to DR, the technologist acquired and developed the images and then transported the patient back to the clinic with the hard-copy film. The physician reviewed images on a view box in the exam room. With DR, images are acquired in half the time, fueling quicker turnaround time of exams and fewer repeats, which decreases radiation exposure, too. With PACS, the orthopedic surgeon can view images before the patient arrives back to in the exam room, which improves patient care and accelerates workflow. 

IS/PACS customization

The benefits of integrated RIS/PACS extend beyond improved patient care. One simple initial post-PACS boost is the elimination of lost films. “We used to have a huge problem with lost films,” admits Hamer, “but now we no longer worry if a resident has a film riding in the back seat of his car.” Children’s Hospital, however, has realized gains beyond basic digital image management processes with integrated RIS/PACS.

“Siemens syngo Workflow RIS offers flexibility in how we control processes. We’ve been able to automate some manual processes,” notes Odom. For example, the systems streamline the process of tracking discrepancies between initial emergency department (ED) interpretations and radiology department diagnoses.

Before the hospital deployed RIS/PACS, ER physicians placed a sticker with an initial interpretation on each film study. Radiologists might not review the study for a final interpretation until 24 hours later. If the radiologist found a hairline fracture missed by the clinician, the technologist needed to pull the film and bring it to appropriate ER nurse for patient follow-up.

Odom used the Siemens syngo Workflow Interactive Document function to create an ED Discrepancy file within the RIS. If a radiologist finds a discrepancy, he can note it on an electronic Interactive Document which then automatically prints in the office of the ER follow-up nurse. She can call the family and close the loop in the RIS.

RIS/PACS solutions also have paved the way for the paperless radiology department at Children’s Hospital. Once again, the Interactive Documents function is critical. Odom created an electronic Technologist Comment sheet. When a tech clicks a patient’s name on the worklist, the document opens and the tech can add relevant patient information such as an updated history that the radiologist needs to complete interpretation. In the traditional environment, such information might be relayed verbally or on paper. At Children’s, there is no more paper, and the radiology department no longer contends with paper-based inefficiencies.

Reaping the benefits of reinvestment

Children’s Hospital of Alabama has significantly improved workflow and patient care since deploying Siemens RIS/PACS and Web-based Viewer in 2003. Radiologists and clinicians are more productive and satisfied in the work environment, says Hamer. Plus, film costs have dropped by $250,000 annually. The hospital’s success stems not only from the initial investment, but also from targeted additional investments in both staff and technology.

IT and PACS support is critical to the success of the project, says Royal. The hospital ensures that it has the staffing resources to optimize its investment by employing two PACS administrators who manage PACS and RIS workflow. In addition, an IT analyst and network analyst manage the technical networking aspects.

During the decision-making process, the team at Children’s realized that successful PACS deployments are enterprise endeavors rather than radiology projects, so hospital leadership approved additional investments in workstations for operating rooms and clinics, enabling clinicians to capitalize on the PACS investment. The hospital boosted acceptance by inviting clinicians to evaluate, trial and select equipment for their departments.

Children’s Hospital is a model of enterprise success, yet continued success hinges on ongoing management and reinvestment. Four years after the initial deployment, Children’s Hospital is poised to transition  its current system into a new state-of-the-art digital image management solution, syngo Imaging, the new Siemens PACS. The hospital also plans to roll out syngo Voice and syngo Portal by the end of 2007.

Royal is among the first Children’s radiologists to adopt syngo Voice, which consists of a speech recognition engine plus command and control and user interface software embedded in syngo Workflow, thereby eliminating the need for a separate speech recognition system. Just a few weeks after implementing speech recognition, Royal has trimmed report turnaround time from 24 hours to immediate; as soon as the report is interpreted, it is available for clinician review. The time-consuming, care-delaying dictation/transcription loop is eliminated.

syngo Portal Radiologist is a web-based information and planning center with user interfaces customized to the radiologist’s role. It provides patient information such as previous reports, lab values and allergies, as well as scanned documents, all in one window. syngo Portal Radiologist provides users quicker access and improved decision-making, such as confirming whether or not an imaging request is appropriate.

The investments in syngo Imaging also will enable progressive image loading to speed up access to large image data files, such as multidetector CT.

The final piece of the puzzle is information infrastructure. Children’s Hospital plans to completely transition from legacy tape, still in the archive to EMC Centera Content Addressed Storage (CAS). The investment will provide faster access to historical studies and allow the hospital to better manage its archive, says Odom.