Originally published on JS PACS, March 5, 2009. A reprint of my article from rt-image, vol. 21, no. 35, September 2008.
PACS is ubiquitous. At one time or another, whether attending the Society for Imaging Informatics in Medicine (SIIM) conference, researching the latest technologies in imaging informatics, or evaluating PACS vendors, we have all heard statements to that effect.
That means a second round of PACS implementation, consisting of ripping out the old and putting in the new, is underway. There can be many reasons an organization may have lost faith in its initial PACS vendor: not providing adequate support, annual costs that are too high, or not improving the software in the direction that is needed.
Or maybe a vendor’s product does not fit into an organization’s workflow. That is a surprising reason, but it is happening to some users. During early implementations of PACS, the goal was to get images stored into PACS without much thought given to the other work that occurred in obtaining the images.
For your next PACS implementation, be sure to fix your workflow woes by making sure you understand how to better integrate PACS into your imaging department’s workflow.
Looking at Workflow Nuances
Before discussing the integration of PACS and radiology workflow, a review of imaging workflow basics is necessary. In its simplest form, the workflow consists of: order entry; receiving the patient; imaging; evaluating the images; releasing the patient; submitting the images for interpretation; interpreting the images (dictation); transcription of the report; and, finally, signing the report.
These steps seem pretty unremarkable until you analyze the nuances that occur at the transitions between each phase. It is at those transition points that imaging informatics can really improve the overall workflow.
In the interpretation process, technology can make enormous improvements both during the transitions and in the interpretation itself. Extra effort should go into completely documenting existing workflows from the very beginning of the imaging process (order entry) through the signing of the final report. Only then should the project to go from analog to digital workflow begin.
Early Oversights
One of the primary things PACS vendors failed to provide in the early versions of their systems was functionality for integrating the radiology workflow nuances into the PACS workflow. In its standard form, a PACS allowed studies to be in one of two statuses: unread and read.
The basic PACS workflow was to image a patient, send the studies to PACS in an unread status, and have the radiologist interpret the study, changing it to read. All the other workflow that occurred in radiology never changed.
Orders were provided via written scripts and entered into a hospital information system/radiology information system (HIS/RIS). This generated a printed paper requisition that served as a transportation slip, patient identifier, a tickler indicating a study needed to be performed, and, ultimately, a document handed to the radiologist stating that a study was ready to be read.
Properly Integrated PACS
Now, with a fresh picture of how radiology workflow used to occur (or still does, for those who didn’t integrate it properly), and an understanding of the stages a study passes through in its lifespan, taking the paper out of the workflow and moving into the digital era should become clearer.
Here is a scenario with a properly integrated PACS:
- The study is ordered and the patient is processed into the department.
- After arrival is completed electronically, the technologist, viewing a RIS-based worklist, sees the order appear on screen.
- The technologist can optionally print a small card for transporting an inpatient to the study. If the patient is an emergency department patient or an outpatient, the technologist simply calls the patient back to the imaging room.
- The technologist finds the study on the imaging device’s modality worklist, selects the correct patient, and begins the exam. In a completely integrated system, initiating the study on the imaging device changes the order’s status in the RIS to “begin procedure” or “start procedure.”
- Images from the study are sent to PACS. Once they arrive, they are in a “performed” status.
- The technologist moves to a PACS workstation, finds the study on a worklist set to display only studies not yet marked reviewed, and opens it. The technologist reviews each image, ensuring it is in the proper sequence, at an appropriate window/level, and of overall diagnostic quality.
- While the study is open, the technologist scans any paper documents generated during the study (contrast questionnaires, etc.) and provides the radiologist with pertinent patient history through a “study notes” type of tool.
- After confirming the study is diagnostic, scanning in documents, and adding study notes, the technologist changes the study from “performed” to “reviewed.” This is the equivalent of handing the radiologist a piece of paper saying the study is ready for interpretation. The study disappears from the technologist’s worklist (set to show only performed studies) and appears on the radiologist’s worklist (set to show only reviewed studies).
- The radiologist opens the study for interpretation and, through properly deployed hanging protocols, sees not only the images but is automatically presented with the patient history and any scanned documents.
- Using voice recognition, the radiologist begins a dictation session from within the open study. After interpretation, the radiologist either reviews and signs the report immediately (placing the study in a “reported” status) or sends it to transcription for verification (placing it in a “dictated” status). Within a short period the review is completed and the report is sent back to the radiologist for signing, at which point the study moves to “reported.”
Easier Said Than Done
While it is easy to document such a system on paper, correct implementation is a completely different matter. There are multiple components that need to be in place to allow such tight integration. Migration to a workflow like the one above cannot happen solely upon the purchase of a PACS.
An appropriately functioning HIS/RIS, voice-recognition dictation, and a document scanning solution all must be part of the implementation. If members of your project team balk at the higher prices that come with this functionality, explain to them why it is needed to improve overall workflow.
After reviewing the ten steps above, I hope it is easier to see that simply allowing a study to be marked read or unread does not fit the bill anymore. Vendors have to work toward providing a PACS that fits the needs of the radiology department.
Since the first generation of mainstream PACS ten years ago, some vendors have realized the need for a multiple-step process for radiology studies. However, whenever I visit SIIM or RSNA and ask a new vendor whether they provide multiple statuses for radiology studies, they still respond, with a curious look on their face, “Well, of course we do. Look here. See? Read and unread.”
I try to explain why I look for more than two statuses; but if, after the first iteration of what I just described, I still get a blank stare, you can bet the conversation is pretty much over.
Points to Ponder
Through this article, I hope to have accomplished two things. First, I hope I have put into print what many PACS administrators have been trying to convey to vendors over the past two years: “Please build us a system that can adapt to what we do.”
Second, I hope I have conveyed to PACS administrators, radiology managers, and IT directors how important it is to find a vendor whose system provides these finer points of functionality. It is definitely worth the extra money to purchase this up front.
It will save you time, effort, and even more money when you see a return on investment more quickly, and it prevents you from having to rework your PACS and radiology workflow two years after the initial purchase. If you don’t properly integrate your workflow up front, I will put my money on the fact that you will be reevaluating PACS vendors within three years.