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IMAGING WORKFLOW Understand Imaging & Imaging Informatics Emmanuel P Bazile, PhD March 2024 1 OBJECTIVES To understand imaging workflow at a hospital Describe the key components and steps involved in the imaging workflow of a large hospital, from patient scheduling to image interpretation and report...

IMAGING WORKFLOW Understand Imaging & Imaging Informatics Emmanuel P Bazile, PhD March 2024 1 OBJECTIVES To understand imaging workflow at a hospital Describe the key components and steps involved in the imaging workflow of a large hospital, from patient scheduling to image interpretation and reporting. Understand the specific requirements, equipment, and protocols for various imaging modalities, including radiography, fluoroscopy, mammography, ultrasound, CT, MRI, and nuclear medicine. Recognize the importance of image quality control, radiation safety, contrast safety, and infection control measures in the imaging workflow. Identify the role of PACS, RIS, and other imaging informatics systems in facilitating efficient image storage, retrieval, and communication of results. Appreciate the significance of interdepartmental collaboration and quality improvement initiatives in optimizing the imaging workflow and patient care outcomes. Discuss the potential impact of emerging technologies, such as artificial intelligence and teleradiology, on the future of imaging workflow in large hospitals. 2 Importance of efficient imaging workflow. KEY COMPONENTS OF THE IMAGING PROCESS: PATIENT SCHEDULING AND PREPARATION IMAGE ACQUISITION AND PROCESSING IMAGE INTERPRETATION AND REPORTING IMAGE ARCHIVING AND RETRIEVAL QUALITY IMPROVEMENT AND SAFETY 3 ❖ Timely and accurate diagnosis and treatment planning ❖ Improved patient satisfaction and outcomes ❖ Optimized resource utilization and cost-effectiveness ❖ Reduced wait times and backlogs ❖ Enhanced communication and collaboration among healthcare providers KEY COMPONENTS OF THE IMAGING PROCESS a. Patient scheduling and preparation - Efficient scheduling systems to manage patient flow - Clear patient instructions for each imaging modality - Coordination with referring physicians and other departments b. Image acquisition and processing - Appropriate modality selection based on clinical indications - Optimized imaging protocols for each modality - Efficient image acquisition and processing workflows - Quality control measures to ensure high-quality images c. Image interpretation and reporting - Timely and accurate image interpretation by radiologists - Structured reporting templates for clarity and consistency - Efficient communication of critical results to referring physicians KEY COMPONENTS OF THE IMAGING PROCESS d. Image archiving and retrieval - Secure and reliable long-term storage of imaging data - Efficient retrieval of prior imaging studies for comparison - Integration with electronic health records (EHR) systems e. Quality improvement and safety - Continuous monitoring and improvement of imaging processes - Radiation safety measures to minimize patient and staff exposure - Contrast safety protocols to prevent and manage adverse reactions - Infection control practices to reduce the risk of healthcare-associated infections PATIENT SCHEDULING Scheduling systems and protocols Single point of contact for patients and referring physicians Streamlined scheduling process across all imaging modalities Efficient management of resources, including equipment and staff Online patient portals for self-scheduling and appointment management Web-based scheduling platforms Real-time updates on appointment availability and wait times Integration with EHR systems for seamless data transfer Urgency classifications (e.g., emergency, urgent, routine) Scheduling protocols based on clinical priorities 6 Standardized scheduling guidelines for each urgency level Coordination with referring physicians to ensure appropriate prioritization PRIORITY LEVELS AND TURNAROUND TIMES a. Emergency cases - Immediate imaging for life-threatening conditions (e.g., trauma, stroke) - 24/7 availability of imaging services and on-call radiologists - Rapid image interpretation and communication of results b. Urgent cases - Same-day or next-day imaging for conditions requiring prompt attention - Prioritized scheduling and reporting to facilitate timely care decisions - Close collaboration with referring physicians to ensure appropriate follow-up c. Routine cases - Scheduled imaging for non-urgent conditions and screening exams - Efficient scheduling to minimize wait times and optimize resource utilization - Established turnaround times for image interpretation and reporting d. Monitoring and auditing of scheduling metrics - Tracking of key performance indicators (e.g., appointment wait times, no-show rates) - Regular audits to identify bottlenecks and opportunities for improvement - Continuous refinement of scheduling processes based on data-driven insights CHECK-IN PROCEDURES a. Designated imaging reception areas - Clearly marked and easily accessible locations - Welcoming and comfortable environment for patients and families b. Patient identification and verification - Confirmation of patient identity using multiple identifiers (e.g., name, date of birth) - Use of barcode scanners or biometric technology for accurate identification - Cross-checking of patient information with HER and imaging order details c. Insurance and payment processing - Verification of insurance coverage and benefits - Collection of copayments, deductibles, or selfpay amounts - Provision of financial assistance information for eligible patients d. Distribution of patient education materials - Modality-specific instructions for exam preparation and post-procedure care - Information on potential risks, side effects, and contrast reactions - Answers to frequently asked questions and contact information for follow-up VERIFYING PATIENT INFORMATION AND ORDERS a. Confirmation of imaging orders - Review of imaging orders for completeness and accuracy - Verification of clinical indications and appropriateness criteria - Consultation with referring physicians for unclear or incomplete orders b. Updating patient demographics and clinical history - Collection of current contact information and emergency contacts - Review and update of allergies, medications, and relevant medical history - Documentation of pregnancy status, last menstrual period, and breastfeeding status c. Screening for contraindications and special needs - Identification of patients with implanted devices, claustrophobia, or mobility issues - Assessment of renal function and contrast allergy history for CT and MRI exams - Coordination of sedation or anesthesia services for patients with special needs d. Obtaining informed consent - Explanation of exam purpose, procedure, and potential risks - Answering patient questions and addressing concerns - Obtaining written or electronic consent for imaging procedures QUICK QUIZ 1. What is the primary focus of the presentation? a) Hospital administration b) Imaging workflow in a large hospital c) Patient satisfaction surveys d) Medical billing and coding 2. Efficient imaging workflow is important for: a) Timely and accurate diagnosis and treatment planning b) Reducing hospital revenue c) Increasing patient wait times d) Limiting collaboration among healthcare providers 3. Which of the following is NOT a key component of the imaging process? a) Patient scheduling and preparation b) Image acquisition and processing c) Hospital cafeteria menu planning d) Image interpretation and reporting QUICK QUIZ 4. Centralized scheduling systems offer the following benefits, EXCEPT: a) Single point of contact for patients and referring physicians b) Streamlined scheduling process across all imaging modalities c) Elimination of the need for staff training d) Efficient management of resources, including equipment and staff 5. Web-based scheduling platforms may include: a) Online patient portals for self-scheduling and appointment management b) Integration with EHR systems for seamless data transfer c) Real-time updates on appointment availability and wait times d) All of the above 6. Which of the following is an example of an emergency case? a) Annual mammography screening b) Follow-up x-ray for a healing fracture c) Stroke imaging d) Routine MRI for chronic back pain QUICK QUIZ 7. Scheduling protocols based on clinical priorities ensure: a) All patients receive same-day imaging b) Patients with urgent conditions receive timely imaging services c) Referring physicians are not involved in the scheduling process d) Resource utilization is maximized, regardless of patient needs 8. Patient identification and verification at check-in may involve: a) Confirmation of patient identity using multiple identifiers b) Use of barcode scanners or biometric technology c) Cross-checking of patient information with HER and imaging order details d) All of the above QUICK QUIZ 9. Verifying patient information and orders includes: a) Review of imaging orders for completeness and accuracy b) Updating patient demographics and clinical history c) Screening for contraindications and special needs d) All of the above 10. Informed consent for imaging procedures involves: a) Explanation of exam purpose, procedure, and potential risks b) Answering patient questions and addressing concerns c) Obtaining written or electronic consent d) All of the above PATIENT PREPARATION (PRE-IMAGING INSTRUCTIONS FOR PATIENTS) a. Fasting requirements - NPO (nothing by mouth) guidelines for specific exams (e.g., abdominal CT or MRI) - Importance of adherence to fasting instructions for patient safety and image quality - Clear communication of fasting duration and any exceptions (e.g., medications) b. Medication adjustments - Instructions for continuing or withholding certain medications before imaging - Special considerations for patients on anticoagulants, diabetes medications, or other critical drugs - Coordination with referring physicians and pharmacists for medication management c. Bowel preparation for specific exams - Cleansing enemas or oral contrast agents for CT colonography or barium studies - Detailed instructions for timing and administration of bowel prep agents - Importance of proper hydration and electrolyte balance during bowel preparation d. Clothing and jewelry restrictions - Instructions to wear loose, comfortable clothing without metal fasteners - Removal of all jewelry, piercings, and other metallic objects for MRI safety - Provision of hospital gowns or scrubs for patients as needed PATIENT PREPARATION (CHANGING INTO IMAGING GOWNS) a. Designated changing areas - Private, secure, and clean changing rooms or cubicles - Adequate space and seating for patient comfort and belongings - Clear signage and directions to guide patients through the changing process b. Assistance for patients with mobility limitations - Availability of staff or assistive devices to help patients change clothing - Accommodations for patients with disabilities, such as larger changing rooms or transfer aids - Sensitivity and respect for patient privacy and dignity during the changing process c. Secure storage for personal belongings - Lockers or secure storage areas for patients' clothing, jewelry, and valuables - Clear labeling and tracking systems to ensure proper return of belongings after the exam - Liability policies and procedures for lost or damaged items d. Provision of comfort items - Warm blankets, socks, or slippers for patient comfort during the exam - Earplugs or headphones to reduce noise during MRI exams - Pillows or positioning aids to ensure patient comfort and minimize movement MODALITY-SPECIFIC PREPARATION: TYPES OF CONTRAST AGENTS PATIENT SCREENING AND SAFETY PRECAUTIONS PREMEDICATION PROTOCOLS FOR PATIENTS WITH CONTRAST ALLERGIES CONTRAST INJECTION TECHNIQUES AND MONITORING 14 Radiopharmaceutical injection for nuclear medicine ❖ Types of radiopharmaceuticals ❖ Patient preparation instructions ❖ Radiation safety considerations ❖ Patient education and postprocedure instructions MODALITIES In medical imaging, modalities refer to the various techniques and technologies used to create visual representations of the human body's internal structures and functions for diagnostic, treatment planning, and monitoring purposes. Each modality employs a unique combination of energy sources, detectors, and image processing methods to generate images with specific characteristics and clinical applications. 16 17 MODALITIES 1. Radiography (X-ray): Uses ionizing radiation to create two-dimensional images of anatomical structures, particularly bones and lungs. 2. Computed Tomography (CT): Combines multiple X-ray projections to generate detailed cross-sectional images of the body, providing excellent visualization of soft tissues, bones, and blood vessels. 3. Magnetic Resonance Imaging (MRI): Utilizes powerful magnetic fields and radiofrequency pulses to produce highresolution images of soft tissues, organs, and physiological processes without ionizing radiation. 4. Ultrasound: Employs high-frequency sound waves to create real-time images of internal structures, primarily used for evaluating abdominal organs, pelvic structures, and fetal development. 5. Nuclear Medicine: Involves the administration of radioactive tracers to visualize physiological processes and metabolic activity, including Positron Emission Tomography (PET) and Single-Photon Emission Computed Tomography (SPECT). 6. Fluoroscopy: Uses continuous X-ray imaging to visualize real-time motion of anatomical structures and contrast media, particularly useful for interventional procedures and dynamic studies. 7. Mammography: Employs low-dose X-rays to create high-resolution images of the breast for early detection and diagnosis of breast cancer. IMAGE ACQUISITION - DIGITAL RADIOGRAPHY VS. COMPUTED RADIOGRAPHY a. Digital radiography (DR) - Direct digital image capture using flat-panel detectors - Advantages: superior image quality, faster image acquisition, and lower radiation dose - Immediate image display and post-processing capabilities - Integration with PACS for efficient image management and distribution b. Computed radiography (CR) - Indirect digital image capture using photostimulable phosphor plates - Two-step process: exposure of the phosphor plate and scanning in a CR reader - Advantages: flexibility, portability, and cost-effectiveness compared to conventional film-screen radiography - Limitations: lower image quality and slower image acquisition compared to DR c. Transitioning from CR to DR - Gradual replacement of CR systems with DR in many radiology departments - Benefits of DR: improved workflow efficiency, reduced repeat rates, and enhanced patient care - Challenges: initial investment costs, staff training, and integration with existing infrastructure d. Quality control and maintenance - Regular quality control testing for X-ray equipment and detectors - Calibration and maintenance of DR and CR systems to ensure optimal performance - Monitoring of reject rates, exposure indices, and other quality metrics - Ongoing staff education and competency assessment for radiographic techniques and patient safety IMAGE ACQUISITION - DIGITAL RADIOGRAPHY VS. COMPUTED RADIOGRAPHY Radiography is a fundamental imaging modality that forms the backbone of many radiology departments. Advances in X-ray equipment and digital detector technology have significantly improved image quality, reduced radiation dose, and enhanced workflow efficiency. The selection of appropriate exposure factors and techniques, coupled with proper patient positioning and immobilization, ensures optimal image quality and diagnostic accuracy. The transition from computed radiography (CR) to digital radiography (DR) has been a significant development in the field. DR offers superior image quality, faster image acquisition, and lower radiation dose compared to CR. However, the adoption of DR systems requires careful planning, investment, and staff training to ensure a smooth transition and optimal utilization of the technology. Regular quality control and maintenance of radiographic equipment and detectors are essential for ensuring consistent performance and patient safety. Monitoring of quality metrics, such as reject rates and exposure indices, helps to identify areas for improvement and guides continuous quality improvement efforts. IMAGE ACQUISITION – ULTRASOUND (ULTRASOUND TRANSDUCERS AND IMAGING MODES) a. Transducer types - Linear array transducers for superficial structures and vascular imaging - Curved array transducers for abdominal, obstetric, and gynecological imaging - Phased array transducers for cardiac and transcranial imaging - Endo cavitary transducers for transvaginal, transrectal, and transesophageal imaging b. Imaging modes - B-mode (brightness mode) for real-time, grayscale imaging of anatomical structures - M-mode (motion mode) for evaluating moving structures, such as heart valves - Color Doppler for visualizing blood flow and detecting abnormalities - Pulsed-wave and continuous-wave Doppler for quantifying blood flow velocities - Elastography for assessing tissue stiffness and characterizing lesions c. Image optimization techniques - Adjustment of gain, depth, and focal zones for optimal image quality - Use of harmonic imaging for improved contrast resolution and artifact reduction - Application of compound imaging for enhanced tissue differentiation and speckle reduction - Utilization of 3D and 4D imaging for volumetric assessment and real-time guidance d. Artifacts and pitfalls - Recognition and minimization of common artifacts, such as shadowing, enhancement, and reverberation - Identification of pitfalls, such as non-representative imaging planes or incomplete examinations - Strategies for overcoming technical challenges, such as obesity or bowel gas IMAGE ACQUISITION – MRI (MRI SCANNER TYPES AND FIELD STRENGTHS) a. Closed-bore MRI scanners - Cylindrical design with a uniform magnetic field - Advantages: high signal-to-noise ratio (SNR), excellent soft tissue contrast, and versatility b. Open MRI scanners - Open design with a vertical or horizontal magnetic field - Field strengths typically lower than closed-bore scanners (0.2T to 1.2T) - Advantages: increased patient comfort, reduced claustrophobia, and easier access for interventional procedures - Limitations: lower SNR, longer scan times, and reduced image quality compared to closed-bore scanners c. Specialized MRI systems - Extremity MRI scanners for dedicated imaging of the hand, wrist, elbow, foot, or ankle - Intraoperative MRI scanners for real-time guidance during surgical procedures - Hybrid MRI systems combined with PET or radiation therapy units for multimodality imaging and treatment planning d. Safety considerations - Strict screening for ferromagnetic objects, such as implants, devices, or foreign bodies - Adherence to MRI safety zones and access control protocols - Monitoring of patients with MR Conditional devices or implants - Availability of MRI-safe equipment and accessories REPORTING Image interpretation and reporting are critical components of the imaging workflow, where radiologists analyze imaging studies and communicate their findings to referring physicians and patient care teams. PACS and RIS systems play a vital role in streamlining image viewing, workflow management, and reporting processes. 24 REPORTING TEMPLATES Structured reporting templates standardize the content and format of radiology reports, improving clarity, consistency, and completeness. The development and implementation of reporting templates involve collaboration among radiologists, referring physicians, and informatics experts. Key elements of structured reports include patient demographics, clinical information, technique details, findings, impressions, and recommendations. Structured reporting facilitates data extraction and analysis for quality improvement and research purposes. 25 PACS (PICTURE ARCHIVING & COMMUNICATION SYSTEM) PACS enables the digital storage, retrieval, and distribution of medical images across the enterprise. It integrates with imaging modalities, workstations, and other hospital systems to provide seamless access to imaging data. Advanced visualization tools, such as 3D rendering and multi-planar reformatting, enhance the diagnostic capabilities of radiologists. Web-based access to PACS facilitates remote viewing and consultation, enabling teleradiology and collaboration among healthcare professionals. 26 RIS (RADIOLOGY INFORMATION SYSTEMS) RIS complements PACS by managing the workflow and tracking of imaging examinations. It integrates with PACS, EHR, and other hospital information systems to streamline scheduling, billing, and resource management processes. RIS also provides reporting and communication tools for radiologists and referring physicians, ensuring efficient dissemination of imaging findings. 28 DIAGNOSTIC WORKSTATIONS Diagnostic workstations and reading environments are designed to optimize image interpretation and reporting. High-resolution, medical-grade monitors ensure accurate visualization of imaging studies. Ergonomic design and appropriate lighting conditions minimize eye strain and fatigue, enhancing radiologists' productivity and well-being. Customizable hanging protocols and image display preferences cater to individual radiologists' preferences and specific imaging modalities. 29 LEVERAGING PACS AND RIS SYSTEMS By leveraging advanced PACS and RIS systems, optimizing diagnostic workstations and reading environments, implementing structured reporting templates, and fostering a culture of quality improvement, radiology departments can enhance the accuracy, efficiency, and value of image interpretation and reporting processes. Effective communication of imaging findings through clear and comprehensive reports is crucial for informed decision-making and optimal patient care. 30 COMMUNICATION OF RESULTS – CRITICAL RESULTS REPORTING PROTOCOLS a. Definition and identification of critical results - Abnormal findings that require immediate medical attention or intervention - Examples: acute intracranial hemorrhage, pulmonary embolism, pneumothorax, testicular torsion - Established criteria and guidelines for determining criticality of findings b. Timely communication of critical results - Immediate verbal notification to referring physicians or patient care teams - Documentation of communication, including date, time, and recipient - Escalation protocols for non-responsive or unavailable referring physicians - Integration with electronic health records (EHR) and clinical decision support systems c. Closed-loop communication and acknowledgment - Verification of receipt and understanding of critical results by the responsible healthcare provider - Read-back or feedback mechanisms to ensure accurate transmission of information - Documented acknowledgment and follow-up actions in the patient's medical record d. Quality assurance and performance monitoring - Tracking and analysis of critical results communication turnaround times - Identification of barriers and opportunities for improvement in the communication process - Regular audits and feedback to ensure compliance with protocols and regulatory requirements COMMUNICATION OF RESULTS – COMMUNICATING RESULTS TO REFERRING PHYSICIANS a. Radiology reports as the primary means of communication - Clear, concise, and actionable reports that address the clinical question - Structured reporting formats to enhance clarity and consistency - Inclusion of relevant images, annotations, and measurements to support findings - Timely finalization and distribution of reports to referring physicians b. Direct communication for complex or unexpected findings - Telephone or in-person discussions with referring physicians to convey nuanced information - Collaborative consultations to guide further diagnostic workup or treatment planning - Participation in multidisciplinary conferences and tumor boards c. Integration with electronic health records (EHR) and physician portals - Seamless access to radiology reports and images within the EHR interface - Notification systems for report availability and critical results - Secure messaging and communication tools for referring physicians to ask questions or request additional information d. Educating referring physicians on imaging appropriateness and utilization - Providing evidence-based guidelines and decision support tools for imaging order entry - Consultation services to guide appropriate imaging selection and protocol optimization - Educational sessions and resources on imaging modalities, indications, and interpretation COMMUNICATING RESULTS Integration of radiology reports and images within the EHR and physician portals enhances the accessibility and usability of imaging results. Notification systems alert referring physicians about report availability and critical results, while secure messaging tools enable efficient communication and follow-up. By implementing robust critical results reporting protocols, leveraging structured reporting and electronic communication tools, and actively engaging with referring physicians, radiology departments can enhance the timeliness, accuracy, and impact of imaging results communication. Effective communication ultimately leads to improved patient outcomes, reduced diagnostic errors, and strengthened multidisciplinary collaboration in patient care. 33 IMAGING INFORMATICS a. Overview of teleradiology - Transmission of radiological images and data from one location to another for remote interpretation - Enables access to subspecialty expertise and 24/7 coverage - Facilitates load balancing and efficient utilization of radiologist resources b. Technical requirements and infrastructure - Secure, high-speed network connections for rapid image transfer - DICOM-compliant imaging systems and viewers for interoperability - Encryption and virtual private network (VPN) technologies for data security - Compliance with HIPAA and other regulatory standards for patient privacy c. Quality assurance and communication protocols - Establishment of service level agreements (SLAs) for turnaround times and reporting standards - Defined communication channels and escalation procedures for critical findings - Peer review and quality control processes to ensure interpretation accuracy and consistency - Regular meetings and feedback sessions between onsite and remote radiology teams d. Benefits and challenges of teleradiology - Improved access to specialist expertise and timely reporting, particularly for underserved areas - Flexibility in staffing and resource allocation, allowing for better work-life balance for radiologists - Potential challenges in communication, cultural differences, and integration with local clinical teams - Need for robust IT support and contingency plans for network or system disruptions IMAGING INFORMATICS Artificial intelligence applications in imaging a. Overview of AI in radiology - Development and integration of machine learning and deep learning algorithms in imaging workflows - Applications in image acquisition, processing, analysis, and interpretation - Potential for improved efficiency, accuracy, and consistency in radiological tasks b. Image optimization and reconstruction - AI-based techniques for noise reduction, artifact correction, and image enhancement - Deep learning algorithms for accelerated MRI reconstruction and low-dose CT imaging - Adaptive image acquisition protocols based on patient characteristics and clinical indications IMAGING INFORMATICS c. Computer-aided detection and diagnosis (CAD) - Automated detection and characterization of abnormalities, such as lung nodules, breast lesions, and intracranial hemorrhage - AI-assisted triage and prioritization of imaging studies based on clinical urgency and suspected pathology - Integration of CAD systems with PACS and reporting workflows for seamless utilization d. Radiomics and precision medicine - Extraction and analysis of quantitative imaging features for disease characterization and prognosis prediction - Integration of radiomics data with clinical, pathological, and genomic information for personalized treatment planning - Predictive modeling and decision support tools for treatment response assessment and follow-up strategies e. Challenges and ethical considerations - Validation and generalizability of AI algorithms across diverse patient populations and imaging protocols - Addressing potential biases and ensuring transparency in algorithm development and deployment - Medicolegal implications and liability considerations for AIassisted decision-making - Maintaining radiologist expertise and critical thinking skills in an AI-enabled environment IMAGING INFORMATICS Imaging informatics encompasses the application of information technology and data science principles to optimize the acquisition, management, and utilization of radiological data. Teleradiology and artificial intelligence (AI) are two key areas within imaging informatics that are transforming the practice of radiology. Teleradiology involves the remote transmission and interpretation of radiological images, enabling access to subspecialty expertise, 24/7 coverage, and efficient resource utilization. Establishing secure, high-speed network connections, DICOM-compliant systems, and robust communication protocols is essential for effective teleradiology services. Quality assurance measures, including peer review and regular feedback sessions, ensure interpretation accuracy and consistency. 37 IMAGING INFORMATICS – AI IN IMAGING AI applications in imaging are rapidly evolving, with the potential to revolutionize various aspects of the radiology workflow. AI algorithms can optimize image acquisition and reconstruction, enabling noise reduction, artifact correction, and accelerated imaging techniques. Computer-aided detection and diagnosis (CAD) systems assist in the automated detection and characterization of abnormalities, helping radiologists prioritize studies and improve diagnostic accuracy. Radiomics, which involves the extraction and analysis of quantitative imaging features, holds promise for precision medicine by integrating imaging data with clinical, pathological, and genomic information for personalized treatment planning and response assessment. 38 IMAGING INFORMATICS – FUTURE By embracing the potential of imaging informatics, including teleradiology and AI applications, radiology departments can enhance the efficiency, accuracy, and value of their services. Successful implementation requires careful planning, robust infrastructure, and ongoing collaboration among radiologists, data scientists, and healthcare stakeholders. As the field of imaging informatics continues to evolve, it is essential for radiologists to stay informed, engaged, and proactive in shaping the future of their discipline. 39 ANY QUESTIONS??? 40 HIM 4023 Health Informatics II Managing Information Resources LO3: Managing System Implementation Managing Information Resources Managing System Implementation Information Systems implementation may include: 1. 2. 3. 4. 5. 6. Acquisition of hardware Computer programming Training Database preparation System testing Final documentation Managing Information Resources 1. Equipment acquisition Whatever the magnitude of hardware requirements, hardware ordering and installation must be carefully planned Space planning must accompany all new equipment orders Managing Information Resources 2. Computer Programming Most systems in healthcare organization use applications software acquired from vendors Some in-house programming may still be required for building interfaces to other applications or changing network configurations to accommodate the new software Managing Information Resources 3. Training: The vendor usually include initial training as part of the contract Vendor → orientation for top management → more specific training for managers and first-line supervisors→managers & supervisors are responsible for training staff in their area The contract with the vendor should specify training responsibilities and costs The healthcare facility should designate a training director Managing Information Resources 4. Database preparation: Data files conversion (manual → computerized) Managing Information Resources 5.System testing: Testing should determine whether specific goals and objectives for the information system have been met Testing data collection and input procedures Errors detecting and correction procedures Testing personnel training Software & Hardware testing Test of completeness of system documentation, including procedures manuals, computer programs, and machine operating manuals Parallel testing Managing Information Resources 6.Final Documentation Completion of all system documentation System documentation should be adequate for effective maintenance of the new system Managing Information Resources System Operation and Maintenance Scheduled Vs. unanticipated maintenance Adequate technical staffing If system maintenance is to be provided by outside contractors or software suppliers, contracts must be negotiated to ensure timely response to requests of emergency maintenance Emergency backup procedures Managing Information Resources Continuous Q.I. Information system QI evaluations should include: 1. Functionality: meeting organizational objectives 2. User satisfaction: meeting or exceeding expectations 3. Costs 4. Benefits 5. Errors and Exceptions: determining if error rates are within tolerance levels Managing Information Resources Organizing for information Management: Role of Chief Information Officer (CIO) The CIO serves two important functions: 1. Assisting the executive team and governing board in using information effectively in support of strategic planning and management 2. Providing management oversight and coordination of information processing and telecommunications systems throughout the organization Managing Information Resources Attributes needed for success CEO: 1. Leadership ability 2. Vision / Imagination 3. Business acumen Thus, a CIO should: Be a leader of information utilization, not a controller of data and technology Focus on long-term strategy and not on day-to-day operations Champion the development and constant monitoring of a strategic information plan Participate as full member of the executive team Managing Information Resources Staffing CIO Management Engineering Department System Development Division Programming Systems Analysis Information Systems Department Software Evaluation & User Support System Maintenance Data Preparation Telecom Department Operations Division Network Maintenance Computer Operations Managing Information Resources Outsourcing Potential benefits of outsourcing include: 1. Reduction of in-house staffing requirements 2. Smaller investment in capital equipment 3. More flexibility in meeting changing requirements and adopting new technology 4. Reduction in the time required to implement new applications 5. More predictable cost structure Managing Information Resources Outsourcing Risks: 1. Too much dependence on vendors. Bankruptcy? 2. High costs associated with vendor fees and profit structure 3. Employment of contractors who do not understand the operation and culture of healthcare organizations Managing Information Resources Executive Management Responsibilities 1. Management must insist on a careful planning process 2. Management should employ a user-driven focus throughout the IS development process 3. Management must take the responsibility for recruiting competent personnel for the design and operation of IS 4. Establish policies and procedures to ensure integration of data files or interfacing among individual IS Managing Information Resources 5. Ethical obligation to maintain security and confidentiality of IS 6. Management should be involved in all major design projects to ensure congruence with organizational goals and objectives 7. Careful system analysis should precede any implementation decision 8. Preliminary design specifications should comply with the master plan for IS Managing Information Resources 9. Detailed system specifications should always be required before any implementation activities take place 10.During analysis and design and implementation phases management should require careful scheduling of all activities and should receive periodic progress reports 11. During the implementation phase, thorough training of all personnel to be involved in the new system should be carried out Managing Information Resources 12. Testing should cover all phases of system operation 13. Provision should always be made for adequate maintenance after an IS is operational 14. Management must ensure that information systems are periodically audited and that all systems are formally evaluated once they are installed and operating normally The Electronic Health Record Existing Hospital Records....... Paper Charts of Patient Health Records are the norm worldwide for recording patient information. All relevant patient information is documented in one file for reference including Lab. results, test results and progress notes. Existing Hospital Records....... ▪ These charts are easy to use. ▪ The same file is used on subsequent admission to the same institution. ▪ And as source of reference for medicolegal cases and research studies. Almost all large health care institutions have a computer database of patients which matches : * Patient’s Hospital I.D. Number * Name * Date of Birth * Address.... This provides a rapid search to match a patient name with a chart no. when retrieving a record from storage. The source of the Electronic Health Record is simply expanding on this database creating an “on-line” record for each Patient. The Electronic Health Record. The Electronic Health Record (EHR) is the future of patient record documentation. There is very wide scope for applications and additions around a centralized record. The EHR can be accessed conveniently by appropriate health professionals to ensure ultimate maximum and optimal patient care. This tutorial discusses the following : Description of a typical EHR. Potential applications. Problems associated with its use. There are many aspects contributing to a typical EHR. PATIENT HOSPITAL ADMISSION GENERAL PRACTITIONER DIAGNOSIS LABORATORY RESULTS DECISIONS TREATMENTS PROGRESS NOTES At Hospital Admission... Admission Details : Patient History Physical Exam. Observations - weight - b.p. temp. - pulse are easily updated and reviewed at subsequent hospital admissions. LABORATORY RESULTS GRAPH Different variables at different dates can be seen at a glance. Variations from the normal values are also easily seen. 350 Glucose 300 Cholesterol 250 3-D Column 3 200 Glucose Normal 150 100 50 0 1/8/95 2/15/95 5/31/95 9/28/95 Lab. results can be received directly from the laboratory and are entered directly, available for the doctor to review. A S.M.A.C. result may look like.... Creatinine 8 Glucose 300 250 Uric Acid umol/l 200 Alk phos u/l 7 6 urea 5 4 Calcium 3 2 Phosphate 1 0 Cholesterol 150 100 LDH u/l AST u/l 50 ALT u/l 0 GGT u/l A Centralized Record can be accessed easily by various hospital departments as illustrated below. Care/Treatment Unit Hospital Ward Patient Location Laboratory Pathology Bacteriology Radiology Physiotherapy Unit Pharmacy PHARMACY ACCESS A Medication Guide such as the one in the next slide gives a comprehensive overview of : Patient Drug History Drug Allergies PHARMACY ACCESS Reasons for prescription Dose Through inclusion of an on-line guide such as BNF or MIMS, warning of impending drug interactions and contraindications may be given MEDICATION MANAGER Patient Name : I.D. No. : Consultant CURRENT : DRUG HISTPORT CURRENT DRUG HISTORY DIAGNOSIS : Urinary Tract Infection Include : All current and expired drugs. OTHER ACTIVE PROBLEMS DRUG Becotide 250 ASTHMA Drugs Available for Diagnostic Profile : CODE AMPICILLIN AMPICILLIN-SODIUM SELECT CANCEL DOSE 2/day Drug Allergies : NONE KNOWN PRESCRIBE RESULTS.... Processing results CT Scan and X-ray results such as this (see next slide) can be processed, reviewed and entered directly into the patient file. The results may be sent to other specialists by the Internet network for consultation. Display Graphics... The index of an Electronic Health Record may look like..... Applications of the E.H.R. COMMUNICATION... One of the advantages of a central record is the ease of communication between - Hospital Departments e.g. for booking of diagnostic tests. -G.P. and hospital physician by email. Standardized, structured messages may be sent from one person to another both of whom are familiar with the format, by the Edifact system (Electronic Data Interchange For Administration, Commerce and Transport). Communication can be made easier via email services Hospital Physician Patient Specialist Surgeon Anaesthetist Other health care personnel General Practitioner Referee TELEMEDICINE... This is the practice of medicine using any data transfer linked with the process of care, in which some aspects of the care are assisted by remotely located professionals. Specialist communications may be made by Video-link. Components of Telemedicine PATIENT SITE PATIENT DATA COMMUNICATION NETWORK TREATMENTS PHYSICIAN IN-CHARGE EXPERT SITE SPECIALIST CONSULTATION EXPERT DATA “Net To The Rescue”..... It was recently reported that two Chinese students at Peking University sent an appeal for help to find a diagnosis for their Chemistry student colleague who had developed a severe illness to which the doctors at Peking Union Medical College hospital had no cure. The medical information was sent to Sci.med newsgroups and within 24hrs was read by a doctor in Washington who recognized the girls serious condition could be due to thallium poisoning. Phoning the hospital in Beijing he advised to check for thallium poisoning. To the initial annoyance of the physicians over 600 email messages were received in reply to this appeal and the general consensus pointed to the same and correct diagnosis. An Internet page is established to monitor the patient - Zhu Ling’s recovery. This can be accessed at http://www.radsci.ucla.edu/telemed/zhuling. THE EHR AS AN INFORMATION SOURCE FOR STATISTICAL RESEARCH. Specific information gathered from a large number of patients for a certain disease with regard to Severity, Duration of symptoms, can be represented graphically or scored. This can be used as a reference for aids to diagnosis. A “Relational Database “ would be of this form and could be incorporated into the EHR. QUESTIONNAIRE ON LIVER DISEASE General Screen Yellow Sclerae.....Age in years Male sex Weight loss Jaundice....Duration (days) Deep Increasing since onset Decreasing Constant Anorexia Nausea/vomiting Symptoms preceded jaundice Haemetamesis pale stool diarrhoea urine dark Abdomen palpable spleen palpable gallbladder tender gallbladder Ascites liver definitely enlarged liver hard liver tender liver irregular obvious mass Other Fatigue Weight loss......Doctors experience in yrs History taken from patient History taken from chart Charts such as the sample In the I.C.U. this type of in the previous slide are correlation, analysis of completed and the Laboratory results and information is coded into biochemical readings computers. from monitors may be From these standard form findings, accumulated from incorporated to predict a thousands of patients, it is patient’s progress and possible to set up a data forecast how long a base. patient may have to stay Through the use of Artificial in intensive care. Intelligence and applying statisitcal rules, the condition This is important to of a given patient - on which hospital staff and the same findings are management as to how available, can be predicted. many places will be available at a given time. APPLICATIONS FOR HOSPITAL MANAGEMENT. CENTRAL RECORDING OF : number of bed days procedures and tests obtained by the patient, units of treatment given in addition to CODING OF DIAGNOSIS, PROCEDURES AND MEDICATIONS will make auditing of patient accounts easier and also more accurate. TRANSMISSIBLE RESULTS MAY CUT DOWN ON THE NEED TO REPEAT TESTS. Conclusion The aim of the EHR is to encompass all underlying structures of paper record in a structured user-friendly format. Good history and physical exam. and clinical observation skills are the key to achieving information which is managed to support clinical decisions and actions taken in patient care. A Centralized record including lab. and procedure results and medication records will enhance patient record interpretation. Coding of Diagnoses, Procedures and Medications will benefit ~ Research ~ Auditing