Chapter 5 Workflow Steps in Radiology PDF

# Chapter 5 Workflow Steps in Radiology ## R.L. "Skip" Kennedy ### Contents - Introduction - Documentation and Process Flow - Key Steps of Radiology Workflow - Radiologist Workflow Steps - Technologist Workflow Steps - Referring Clinician Workflow Steps - Other Personnel with Cri...

# Chapter 5 Workflow Steps in Radiology ## R.L. "Skip" Kennedy ### Contents - Introduction - Documentation and Process Flow - Key Steps of Radiology Workflow - Radiologist Workflow Steps - Technologist Workflow Steps - Referring Clinician Workflow Steps - Other Personnel with Critical Workflow - IHE Workflow Models - Goals of Workflow Analysis - Summary - Self-Assessment Questions ### 5.1 Introduction The understanding of workflow in Radiology is part of the larger domains of business process analysis BPA and business process modeling BPM. Extensive literature exists in the business administration literature outside of imaging informatics. However, some special and particular aspects of digital image management need to be addressed to fully understand how data and processes interact in the context of a fully digital imaging environment. Fortunately, the integrating the healthcare enterprise IHE frameworks offer particularly useful models that specifically address and leverage both HL7 and DICOM capabilities in regard to workflow. Further, it is increasingly important for us to expand the scope of our understanding regarding imaging workflow to include the overall healthcare enterprise to embrace the electronic medical record EMR and other enterprise systems and to extend beyond the immediate radiology context into other medical imaging domains such as cardiology, dermatology, pathology, surgery, ophthalmology, and those other medical disciplines now increasingly engaged in digital imaging. **Definition 5.1:** Integrating the Healthcare Enterprise is an initiative that has created a framework for medical workflow by which different electronic information systems can exchange information. ### 5.2 Documentation and Process Flow Although we must still apply the specifics of HL7 and DICOM to traditional business process analysis and modeling to be fully useful for our purposes, the tools available from the general disciplines of business administration remain extremely valuable. Process flow diagramming, in particular, offers us great value for documentation of information flow and the various event triggers that drive imaging workflow. Several standard texts exist for understanding process documentation and are not covered here. However, it remains an essential exercise for any PACS and RIS deployment to document intended workflow using the standard business process documentation tools available. Figure 5.1 is an example of a typical such diagram, incorporating RIS, PACS, report management, and EMR workflow steps. The key to this process is to design workflow to achieve desired clinical results to the degree possible with the new systems, rather than to simply re-implement electronically those same workflows that defined film-based radiology imaging. We will need to build what is needed in the present and future rather than rebuild those workflows and processes we have utilized in the past. **Further Reading 5.2:** - *Business Process Analysis*. London: International Thomson Business Press, 1997 - *Business Process Improvement Workbook: Documentation, Analysis, Design, and Management of Business Process Improvement*. New York, McGraw-Hill, 1997 - *Fundamentals of Business Process Analysis: The Capture, Documentation, Analysis and Knowledge Transfer of Business Requirements*. Philadelphia, PA: Annenberg Communications Institute, 1999 ### 5.3 Key Steps of Radiology Workflow One of the essential points of understanding the HL7 and DICOM aspects of digital image workflow is the concept of event triggers. **Key Concept 5.3:** A single-workflow event may produce a cascade of other workflow events, some of which are automated, and some of which rely on manual input. **Further Reading 5.4:** - *Work flow redesign: the key to success when using PACS*. AJR Am J Roentgenol. 2002 Mar; 178(3):563-6. **Example:** The action of a technologist clicking on a button on the CT scanner, and initiating a DICOM transmission to the PACS of the completed study may trigger yet other automated actions further in the workflow, such as potentially the PACS forwarding a HL7 message to the EMR signaling new image availability. Understanding these workflow triggers, in most cases, involves understanding the state conditions of the underlying protocols typically DICOM and HL7, but increasingly also web services such as SOAP as well as the actual events that these represent in the actual business logic. The translation of the business logic to the appropriate protocol messaging state is the key to the implementation of functional workflow in digital imaging. ### 5.3.1 Radiologist Workflow Steps - Log in to PACS - Set worklist filters/choose cases - Launch case - Collect clinical data/prior exams - Review and interpret images - Dictate report - Personally convey urgent or unexpected findings - Review and sign report may be performed individually or as a batch - Protocol and check ongoing cases ### 5.3.2 Technologist Workflow Steps - Determine next patient/claim patient in RIS - Retrieve patient - Determine protocol - Obtain images - Check images for quality - Postprocess to create additional images - Send images to PACS - Complete study in RIS ### 5.3.3 Referring Clinician Workflow Steps - Order study - Computerized physician order entry - Paper order in patient's chart - Verbal order to nurse or clerk - Provide clinical information for radiologist - Review radiologist report - Online - In the EMR - Paper report in the patient's chart - Contact radiologist for clarification/discussion ### 5.3.4 Other Personnel with Critical Workflow - **Transcriptionist** - workflow strongly determined by speech recognition and dictation software - **Nurses** - Radiology nurses - Ward nurses ### Our Experience 5.5: Paperless Workflow One of the major areas of workflow inefficiency in most radiology departments is the paper tokens that are passed from one person to another to follow the flow of the patients and their images through the departments. Changing from a paper-based to a paperless workflow is very inviting, but it is easy to get caught by minor issues that will prevent full implementation. Usually, the workflow of the radiologist is carefully considered, and if dictation is integrated with PACS, then the PACS will have the software elements necessary to abandon paper. But do not forget that other personnel rely on those same paper tokens! Taking them out of the hands of the radiologists may not be adequate unless communication software between nurses, techs, and physicians is robust. For example, technologists may use the paper requisitions to write notes to the radiologist, explaining why an exam is of suboptimal quality or providing new clinical information. There needs to be an alternate means of communicating that information when you go paperless. - PACS support personnel - need dashboards to stay ahead of hardware failures. - File room clerks - even after the transition to PACS, still needed to find comparison films and create CDS - Ward clerks - often responsible for actually ordering the study, upon a physician's order. - Transportation personnel - take inpatients from their rooms to radiology and back. ### 5.4 IHE Workflow Models In the IHE model, imaging workflow is comprised of a hierarchical sequence of several components: order, requested procedure, procedure step, worklist, and reports. Defining and combining these steps and components allow us to design digital imaging workflow. The formalization and rigor of the IHE workflow model provide us with a more exact semantic context for the steps of digital image workflow and allow us to merge different workflow models with shared context. - **An order** represents a formal request, typically from a referring provider, for a specific or general service, representing certain actions or work products. Since reimbursement is closely linked to order status and processing, orders most typically originate from external systems, such as HIS or EMRs supporting electronic order entry. These are typically transmitted to a RIS and to PACS to support integration and automated modality worklist processing. - **A requested procedure** represents a fundamental work unit, typically performed together within an encounter that is comprised of one or more procedure steps typically performed together during this patient encounter. Multiple procedure steps may be required to satisfy the procedure and the corresponding order. An example of this might be for a "CT Head Scan" within the EMR order entry system. - **A procedure step** represents the discrete and indivisible steps that comprise the requested procedure as an entity. Since these are interrelated, they need to be performed within the encounter itself, or in a designated sequence. These are represented within a worklist and are typically associated with specific common procedural terminology CPT coding. In other cases, procedure steps may also represent required steps that may or may not be performed within an encounter, such as treadmill or radionuclide injection. - **A worklist** represents procedures and procedure steps that are to be performed. Typically, now, this is made available and transmitted to the performing modality via the DICOM modality worklist service, to avoid repeated manual data entry and resulting data entry error. Design of work-list management is one of the most essential PACS design criteria, as it heavily contributes to both efficiency as well as data integrity of the imaging products of reports and the images themselves. - **Reports** are most typically the result of radiologist interpretation, although there is now an increasing focus on structured reporting resulting from technologist workflow processes as well as automated content (such as protocol details and tabular data) directly from the modalities themselves. **Further Reading 5.6:** - *IHE Radiology Technical Frame work White Paper 2004-2005*. IHE-Radiology Technical Committee. - *Integrating the Health care Enterprise: A Primer Part 2. Seven Brides for Seven Brothers: The IHE Integration Profiles.* Radiographics. 2001; 21:1343-1350. - *IHE website.* Available at: http://www.ihe.net - **Scheduled workflow SWF** integrates ordering, scheduling, imaging acquisition, storage, and viewing for radiology exams. - **Patient information reconciliation PIR** coordinates reconciliation of the patient record when images are acquired for unidentified e.g., trauma, or misidentified patients. - **Postprocessing workflow PWF** provides worklists, status, and result tracking for postacquisition tasks, such as computer-aided detection or image processing. - **Reporting workflow RWF** provides worklists, status, and result tracking for reporting tasks, such as dictation, transcription and verification. - **Import reconciliation workflow IRWF** manages importing images from CDs, hardcopy, etc., and reconciling identifiers to match local values. - **Portable data for imaging PDI** provides reliable interchange of image data and diagnostic reports on CDs for importing, printing, or optionally, displaying in a browser. - **Evidence documents ED** specifies how data objects such as digital measurements are created, exchanged, and used. - **Simple image and numeric report SINR** specifies how diagnostic radiology reports including images and numeric data are created, exchanged, and used. - **Key image note KIN** lets users flag images as significant e.g., for referring, for surgery, etc. and add notes. - **Consistent presentation of images CPI** maintains consistent intensity and image transformations between different hardcopy and softcopy devices. - **Presentation of grouped procedures PGP** facilitates viewing and reporting on images for individual requested procedures e.g., head, chest, abdomen that an operator has grouped into a single scan. - **Access to radiology information ARI** shares images, diagnostic reports, and related information inside a single network. As these integration profiles expand and refine further, they serve as templates for vendor interoperability, fully supported by the technical specifics of DICOM and HL7 in the IHE framework documents. Figure 5.2 details the first, and probably most fundamental, of the IHE Integration Profiles - the **Scheduled workflow profile**. Dozens of other profiles now exist, and more are in development. Essentially all aspects of digital imaging workflow are now represented within the various IHE integration profiles currently available. ### 5.5 Goals of Workflow Analysis - The goal for any workflow analysis and workflow engineering process is, ultimately, to improve and enhance the workflows for efficiency, reliability, fault tolerance, and transparency to the clinical users. - Workflow that represents many discrete steps that the clinical users must remember individually is to be avoided. - Where possible, the concept of user interface "navigators" is particularly valuable when applied to sequential repetitive workflow. - Where feasible, any given step that requires a predecessor step to be meaningful should not be available until the requisite predecessor has been completed. Such as a radiologist reporting on a study for which a technologist has not yet completed or performed QA. - Exception workflows for which these steps must, necessarily, be performed out of normal sequence should be available, but still allow process state recovery. As an example, the IHE profile for patient information reconciliation PIR for reconciliation of unidentified or misidentified patient/study information. - A further goal for digital imaging workflow design is to facilitate interoperability. This is key deliverable of the IHE initiative. - Vendor-specific workflow is seldom capable of addressing enterprise requirements while a "single-vendor solution" may be feasible with the confines of radiology, few, if any, vendors would be capable of addressing the needs of multiple departments and the enterprise EMR. - One of the fundamental goals of IHE is to facilitate vendor interoperability by the abstraction of the various system roles and the definition of standard protocol framework to the construction of workflows. ### 5.6 Summary The design and testing of digital imaging workflow will be addressed more fully in Chapter 17, but the basics of approaching an understanding of these workflows lie in three areas: - leveraging existing business tools outside of Informatics for workflow documentation and analysis methodologies. - understanding the technical specifics of DICOM and HL7 as they apply to and drive digital imaging workflow. - understanding and leveraging the IHE workflow models as templates for local workflow. A great deal of particularly valuable work has been done in developing the IHE integration profiles and frameworks, and the study of these will prove valuable to any effort regarding workflow engineering. While it is likely that not every aspect of the IHE integration profiles may apply precisely to all specific local clinical requirements, it is equally unlikely that any institution developing and deploying PACS at this time would not find the majority of the IHE workflow models directly applicable and valuable. The use of the IHE technical frameworks for achieving vendor interoperability as well as regional institutional interoperability in the future are key developments and resources in these efforts. Digital imaging has now moved well beyond the confines of radiology, both in terms of multiple imaging departments as well as servicing the entire enterprise as its customer base. Early implementations of PACS and RIS were, by necessity, limited in scope, but modern digital imaging workflow has as its expanded scope, multiple departments and enterprise access. The culmination of these changes will almost certainly be enterprise, regional, and finally national EMRs that encompass digital imaging. We must build workflows today to support and embrace these futures. **Pearls 5.8:** - Workflows for different personnel are inextricably linked. - IHE provides a useful framework for radiology workflow. - Workflow improvements should address the efficiency, reliability fault tolerance, and transparency of workflow. - Improved communication between different software programs allows for more efficient workflow. ### Self-Assessment Questions 1. Which of these is **NOT** a usual element of radiologist workflow? - obtain images - convey unexpected findings - protocol ongoing cases - collect clinical data 2. Which of these is **NOT** a usual element of technologist workflow? - send images to PACS - check images for quality - postprocess the study to create new images - bring the patient to the radiology department **Further Reading 5.7:** - *Healthcare Informatics, November 2007 Diagnostic Imaging: PACS and Radiology Information Systems.* Available at http://v.healthcare-informatics.com/Media/Document Library/Diagnostic%20imaging.pdf