RIS and PACS are mature technologies, but that doesn't guarantee they will work effectively for a hospital if they're acquired and implemented without forethought and planning. To help avoid the pitfalls, Simon Waddington, radiography lead with U.K.-based Circle Health, provided some valuable tip and tricks earlier this month at a London seminar, entitled Radiology Information Systems and PACS: Moving Beyond the National Programme.
"I have learned from experience that the best software systems available won't solve problems relating from poor workflow or ill-thought-out processes," Waddington told AuntMinnieEurope.com in an interview. "However, poor software systems can be usable if there is good workflow and strong staff compliance in using the system."
When planning to add or replace a RIS, PACS, or integrated RIS/PACS, it's important to map out and fully understand the workflow. It's also important to engage and get input from everyone who will touch the technology. People need to own the project, not be forced into it. A team of champions is needed, comprised of representatives of the scheduling and clerical staff, radiographers, department administrators, and radiologists. Everyone needs to get involved defining the best workflow processes and what is needed. Waddington, a speaker at the 18 January seminar about practical experiences and integration challenges of radiography-specific IT systems into the regional and national implementation of electronic health records, commented that this was not a revolutionary idea, nor for that matter was the process of planning for a PACS. It's been written about in great detail for two decades.
"What's important is to make sure that people and the project are what's most important, not the methodology," he said. "This is as important with respect to implementing new radiology IT technology as it is for providing replacement systems. There is always room for improvement. Take advantage of this."
Electronic order entry systems
Many established RIS/PACS don't have electronic exam ordering systems. These offer major advantages, such as legible form requests and no lost forms. An electronic exam ordering system supports the establishment of a centralized remote appointment desk. It reduces delays that can occur to obtain preapproval for ordered exams. It is especially beneficial when a single specialist consultant radiologist is responsible for approving requests for exams in multiple locations.
An electronic order reporting system can also have major disadvantages. It may not have the capability to allow a requesting clinician or clinical support staff to change clinical information. It may not support the required workflow. It may crash or otherwise have downtimes during which exams cannot be ordered. It may be subject to the lack of robustness of a hospital IT infrastructure that is outside the control of the radiology IT staff.
This three-monitor configuration, one for RIS and the other two for image review, optimizes reading delivery. Radiologists should be asked about shortcuts so that they can be shared with others. Image courtesy of McKesson.An electronic order reporting system requires a financial investment in software, time, and cost to implement and integrate. It requires a commitment to training at implementation, with refresher courses, and for a continuous stream of new users, both referring physicians and members of the radiology department, for the product's life cycle. It needs ongoing IT support and most likely a 24/7 accessible help desk to answer questions. And it requires a viable process for ordering exams during scheduled or unplanned downtime.
An electronic order reporting system can be undermined in various ways. Referring physicians may find workaround methods to avoid using the system. They may share their passwords, which is comparable to the practice of having a stash of presigned forms. Radiologists may initially find it easier to use paper printouts of the forms to vet exams. They need to be weaned from this, much like x-ray film, and their complaints dealt with without caving in to demands.
Electronic exam order requests allow for the centralizing of an appointments office into one location. It is essential that all staff follow the same process, and that the appointments diary system visually resembles an appointment system and is easy to use, Waddington said. He also suggested that implementers resist the temptation to allow for an interim period in which the orders can be printed out for vetting. Management needs to support this decision.
Workflow process planning and vetting
The process of vetting an exam order to verify its clinical validity needs to be simplified as much as possible, according to Waddington. Aim to have at least 90% of all exams vetted by an established protocol that is automated as much as possible, he suggested. Document standard operating procedures and adhere to them. When a radiologist does need to vet an exam, the process must be fast and easy to use.
Some of the "gotchas" that need to be carefully thought out and for which standard operating procedures should be developed include the following:
- The process of exam cancellation by a patient: How is the ordering physician notified, and how is this documented?
- The process of requesting more clinical information from a referring physician because additional information is needed to vet an exam.
- When a physician responds to the request to provide this information, how is it entered back into the system?
- What happens if the physician fails to respond? And how are the physician and patient notified?
The system may be easier to manage if some exams don't require an appointment; rather, a patient just shows up during designated hours for an x-ray or ultrasound exam. An open schedule for routine and anticipated exams can simplify operations.
Waddington also referred to a protocol put in place with respect to vetting at the Great Western Hospitals NHS Trust in Swindon. The radiology department found that it was more efficient by eliminating individual pre-exam preparation and prevetting the majority of exams, he explained.
The department discovered that by establishing standard patient advance preparation guidelines, it became much more productive. Rather than try to determine if each individual patient needed to arrive with a full bladder prior to an ultrasound exam, for example, all patients were told to arrive with a full bladder. If this was unnecessary, they could use the toilet. The department realized that while a few cases may need a radiologist to advise about patient preparation, this was unnecessary for the majority of patients.
When an exam was discovered by vetting to be incorrectly ordered, the department found a way to perform the necessary exam for the patients by being flexible, Waddington said. If a patient arrives for a scheduled CT exam but really needs an MRI exam, even when the MRI schedule is fully booked, the staff finds a way to accommodate the patient that day. Flexibility combined with an electronic ordering system have eliminated all the delays of prevetting before booking an exam.
Evaluating electronic ordering systems -- and for that matter, all radiology IT software and hardware
"Don't assume anything about a commercial system," Waddington emphasized. When conducting due diligence for a system after thoroughly analyzing workflow and needs requirements, a potential customer must ask questions. "Gather information. Listen to your potential suppliers. Talk to their customers. Ask questions. Just because you want something from a vendor who's well-established in the radiology IT marketplace doesn't mean that the vendor can offer what you want, or that it is available when you want it -- it may be in the process of development -- or that it will work for you in the way that you anticipate," he said. In other words, deal with tangibles.
Another piece of advice Waddington emphasized was not to reinvent the wheel, but rather learn from advice given and processes that work for other implementers. But he warned that it is imperative not to assume that what works for the radiology department will work for exam requestors. "If you want clinicians to cooperate with radiology, you need to make a system that is fast and easy to use, that is logical, that doesn't contain repetitive data entry requirements, and that will not cause requestors delays," he said.
Other advice included negotiating sensible software licenses for any type of radiology informatics software. Having a software license for each radiologist to use at each possible workstation could be very expensive, Waddington noted. Radiologists tend to be creatures of habit. The majority won't be inconvenienced if they are limited to several specific locations. He also recommended negotiating for licenses based on concurrent use rather than the number of users whenever possible.
Waddington also pointed out that a radiology department can save money if it determines the hardware requirements that a workstation needs based on the software that it is going to use. Some computer workstations have more RAM than they need, and others could be much more efficient if more RAM was added, he noted.
"Just as workflow needs careful analysis and scrutiny, so also should software and hardware requirements be scrutinized. The key is to save money without compromising efficiency of radiologists. In today's economy, this needs to be done," Waddington said.
Waddington, a radiographer by profession, first got involved with a RIS in the early 1990s when he went to work at the Royal United Hospital Bath NHS Trust. The hospital was using a primitive computerized radiology order entry system, in which electronic exam orders were transmitted to the radiology department, where they were automatically printed. They were booked manually from this paper copy. In 1999, Waddington moved to Southmead Hospital, where a slightly more sophisticated RIS was in operation. There he gained experience as a RIS/PACS manager when the hospital implemented a RIS, PACS, and speech recognition dictation system. In 2010, he joined Circle Health to head its enterprise RIS/PACS operations.
Circle Health provides healthcare services in private hospitals and clinics. An employee co-owned partnership, it opened its first new-build hospital, CircleBath, for both private and NHS patients in Bath in March 2010. It subsequently opened Circle Clinics in Stratford-upon-Avon and Windsor. In November 2010, it was awarded a contract to run the Hinchingbrooke Healthcare NHS Trust in Huntington and the Nottingham NHS Treatment Center in October 2011. A new hospital is under construction in Reading.
Circle Health currently has seven sites that perform diagnostic imaging exams. Waddington had the responsibility to establish an enterprise imaging informatics network (McKesson) from inception.
