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Radiology Workstation Design for the Medical Intensive Care Unit

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Radiology Workstation Design for the Medical Intensive Care Unit Radiology Workstation Design for the Medical Intensive Care Unit Document Transcript

  • Radiology Workstation Design for the Medical Intensive Care Unit Adrian Moise and M. Stella AtkinsThe ``one-size-®ts-all approach for radiology work- decisions based on limited and usually incom-station design is not good enough anymore. While plete information on patients who are strangersmost of the picture archiving and communicationsystem (PACS) vendors are racing to add more fea- and for whom prior medical information is nottures to the radiology workstation, there is little in- available. This situation creates high risks forterest in addressing the speci®c needs of other malpractice (third after obstetrics and operatinghospital departments. Signi®cant delays in the avail- room).2 For acutely ill patients, the delay be-ability of radiology reports are often caused by the fore the formal report becomes available isfact there is not enough Intensive Care Unit (ICU)volume to justify a full time radiologist. Consequent- sometimes too long and may a€ect patient care.ly, the radiologist assigned to cover the ICU exams, Therefore, in a traditional ®lm environment,most likely working from a different building, will ICU sta€ must run to the Radiology Depart-read the ICU exams only at certain times, depending ment to obtain a report indication, as it is rareon the limitations for remote image availability. This for a radiologist to be present in the ICU. Whilepaper addresses the main objectives in designing adigital radiology workstation for use in the medical this solution can be fast and complete, it o€ersICU (MICU), requiring enhancements to current PACS little opportunity for improvement [1]. Leavingsystems. Our suggestions for PACS improvement the ICU is inconvenient for the ICU members,follow the ICU digital work¯ow starting with the who are generally busy with patient case.3transfer of the images from the modality, continuing The introduction of Picture archiving andwith the presentation of the radiology examination todifferent types of users (radiologists or ICU staff), up communication system (PACS) and the avail-to the creation and distribution of the reports. ability of a reading station in the ICU can re- duce the delay in communication between theKEY WORDS: radiology workstation, PACS, ICU, im- ICU physician and the radiologist. However, inage display the early stages of PACS implementation, ®lm digitization was a major bottleneck in the prompt ¯ow of radiological information to theM EDICAL ICU DEPARTMENTS have a grouping of beds for patients requiringcritical care that require intensive monitoring. ICU. Film digitization was both unreliable (19% of exams never digitized) and slow (62 minutes median time between exam acquisitionOften patients only stay for a short time. Non- and ®lm digitization), contributing to a medianroutine (problem-speci®c) chest radiographs time elapsed from exam completion until thecomprise 25% to 40%1 of all ICU examinations.These radiographs require an extreme range ofintensities to provide diagnostic information onall parts of the chest, the endovascular lines and From the Medical Imaging Laboratory, School of Com- puting Science, Simon Fraser University; Society for Com-drains. Magnetic resonance, computed tomog- puter Applications in Radiology, Burnaby, British Columbia,raphy, or ultrasound is sometimes used to Canada.provide additional information on the status of Correspondence to: Adrian Moise, Medical Imaging Lab-a patient. oratory, Simon Fraser University, 8888 University Drive, Intensive care unit physicians require more Burnaby, BC, Canada V5A 1S6; e-mail: {amoise}@cs.sfu.ca Copyright Ó 2002 by SCAR (Society for Computer Ap-rapid access to images and radiology interpre- plications in Radiology)tations than physicians in most hospital settings. Online publication 19 March 2002The ICU physicians are asked to make rapid doi:10.1007/s10278-002-5025-xJournal of Digital Imaging, Vol 15, Suppl 1, 2002: p 151-155 151
  • 152 MOISE AND ATKINSreport dictation of 5 hours.4 More recently, in tions. If automatic loading of the next examin-environments where ®lm digitization has been ation is implemented in PACS, the next study toreplaced by computed radiography (CR), sig- be displayed will be selected in priority se-ni®cant improvement in the availability of im- quence. This feature requires tight integrationages and reports has been achieved. with RIS/HIS and all imaging modalities. During the ®rst phase of a PACS implemen- A noti®cation mechanism must inform thetation5 the median elapsed time from exam radiologist when a STAT exam is sent from thecompletion until interpretation by radiologist imaging modality into the PACS system. Whenwas 1.86 hours, while the median elapsed time such a noti®cation arrives, the radiologist mayfrom exam completion until report transcrip- choose to ``park (put on hold) the current ex-tion was 3.43 hours Horii et al. reported that amination and to load the ICU exam for re-PACS shortened the time from request to image porting, or ®nish the current exam and read thereview by the ICU physician, from 1.35 hours newly arrived STAT exam next.to 0.93 hours.6 Other reported bene®ts of theintroduction of PACS include a reduced num- FEATURES OF THE PACS WORKSTATIONber of examinations per patient day (from 1.3 IN THE ICU‹ 0.60 to 1.09 ‹ 0.69), a reduced medianelapsed time from exam completion until image The digital work¯ow should be improvedreview by ICU sta€ (from 2 hours 32 min to 1 with the use of contextual information speci®chour 35 minutes), and a decreased time to to the ICU. The patients currently in the ICUclinical action (from 3 hours 21 minutes to 2 ward should be listed by name or bed number.hours 6 minutes).7 If tracking the patients position in the ICU is Despite all these reported improvements in not done automatically, bed initializationthe report turnaround time, the delay from functions such as Move, Clear, and Init shouldimage acquisition until report transcription is be implemented.8 When idle, the radiologystill too long for the ICUs requirements. workstation should display a gestalt of theConsequently, running to the Radiology De- current patient situation, such as a thumbnailpartment to get the interpretation on a critical image of the last examination for every patient.examination is still the primary means by From this ``emergency review or ``View allwhich ICU sta€ can get fast exam interpreta- beds mode9 (a 4 ´ 5 layout of 256 ´ 256 pixeltion. We propose extensions to the PACS de- thumbnails), any patient can be selected bysign that will lead to improved patient care. name or by the thumbnail for the correspond-Our goal is to allow the ICU sta€ to remain ing bed number. For a ``historical review ofwithin view of their patients, by providing di- the selected patient, ICU speci®c hanging pro-rect and convenient access to radiology images tocols10 should be used to minimize the timeand reports on a digital workstation within the wasted in rearrangement of the images on theICU. This will require enhancements to the monitors and in unnecessary soft-copy manip-PACS work¯ow in both the radiology and the ulation of the images.11 For example, the mostICU departments. recent examination should be displayed in real- size on the left monitor, and the last four priors FEATURES OF THE PACS WORKSTATION should be displayed four up on the right screen IN THE RADIOLOGY DEPARTMENT in reverse chronological order (other authors suggest 6,12 86 and 168 ``iconi®ed priors). A The image review workstation should be tai- double-click with the mouse could be used onlored to the users pro®le. For the radiologist, a any of the prior images to switch its displayspecial ®ltering mechanism of current unre- back and forth between real size and the four-ported studies must be available to list the pa- up layout. A ``daily overview mode, listing fortients currently in the ICU. A priority comparison the two most recent exams formechanism in the PACS is required to allow every patient, will be particularly useful at the``STAT (urgent) examinations coming from beginning/end of shift rounds. The tools avail-the ICU to move ahead of routine examina- able for diagnosis will adapt to the utilization
  • RADIOLOGY WORKSTATION DESIGN 153pattern7 corresponding to the users role (radi- to the image review mode (radiology interpre-ologist or ICU physician) and to the type of tation available) or interpretation mode (re-disease investigated16 (information supplied by quires extra attention and possibly moreRIS/HIS). advanced image manipulation tools). Whenever The digital workstation should be ¯exible en- the study displayed has an associated radiologyough to deal with incorrect or incomplete patient report (the image was already interpreted), ademographic information. Image comparison reduced, disease oriented16 set of features forshould be possible under common situations ``streamlined17 ``heads-up reading should besuch as misspelled names or multiple identi®ca- presented to the user. Some tools, such astion numbers for the same patient. A ``smart live Window/Level (W/L) zoom and pan, should beupdates noti®cation mechanism should check ``always on through a dedicated mouse buttonfor close matches of patient information of every or by using custom input hardware. Because ofnew study against the list of patients currently in the wide variation in radiographic exposure, anthe ICU ward. This mechanism must inform the automatic adjustment of brightness and con-ICU sta€ when a new image or radiology report trast can signi®cantly reduce the W/L manipu-(either formal or ``wet) is available. After the lation required for study comparison.18 CRnew information is examined, the noti®cation display presets based on image processing op-may be turned o€, depending on the users role timized for speci®c ®ndings and pathologies19(nurse, resident, or faculty). could facilitate image comparison and stan- In some clinical environments, a money-sav- dardize display across examination type. Othering strategy could allow the ICU physicians to tools (grayscale invert, edge enhancement,perform the ®rst interpretation of radiology magni®er glass) should be available on a tool-examinations.13 This is not a new trend, be- bar and on a context-sensitive right-click con-cause ICU physicians often act as substitutes for text menu. Infrequently used tools should beother specialists (cardiologists, gastroenterolo- ``hidden, but available on user request orgists, orthopedists, general surgeons). For better whenever the radiologists interpretation is notpatient care, the radiologist should still be con- available. The user interface should be adaptive,sulted on high-risk patients or on exams dicult corresponding to such factors as the users role:to interpret. The workstation must detect the attending physician, fellow, resident, intern.availability of reports for the current examina- Another criterion relevant for the user interfacetion, either from the users selection (the study customization is the manipulation pattern as-was opened for review or for reporting) or by sociated with the type of study: for example, forquerying the RIS/HIS. The PACS should sup- Pediatric ICU, W/L and invert will be oftenport preliminary interpretation from ICU phy- used to detect the tips of the catheters or edgessicians, which will be available when the on pulmonary opacities, while for Neonatalradiologist dictates the ®nal report.14 A noti®- ICU, zoom is used for detection of subtle tubescation mechanism should be implemented to and automatic shuttering (removal of unex-inform the ICU sta€ of the various discrepancy posed background20).types (serious, moderate, or low risk). Reliable and FastÐNew Toolkit Automation of Most Routine Tasks and User Interface Productivity will be high when the interpre- Reliability (up-time 99.999%) and speedÐ tation time, user fatigue, and tool usage arethese are the most important objectives for the reduced without a negative impact on the pa-radiology workstation in the ICU. The use of tient care. An ICU oriented hanging protocoltwo or four monitors is recommended to reduce should deal with the automatic loading of rel-the time for image review and interpretation as evant priors, automatic image orientation,21compared with single-monitor workstation.15 and automatic shutter (especially for pediatricThe user interface presented should be tailored images). To encourage the use of image-pro-to the task facing the ICU sta€, corresponding cessing tools by ICU personnel, a ``return to
  • 154 MOISE AND ATKINSoriginal and one level ``undo should be im- pose a software metaphor inspired from oper-plemented and easily accessible. ating systems design: Various ``¯avors of workstation will share a common kernel; the Improve Availability and Use of extra functionality layers will be wrapped Radiographic Reports around the kernel to ensure custom-built speci- ®city. Such bundled packages may include video Interpretation of radiography by the non- teleradiology, DICOM viewing station, and fullradiologist physician has an impact on the teleradiology;23 among other features. This wayaccuracy of radiographic interpretation, so several specialized devices can be eciently builtthe PACS/workstation design should focus on on the same skeleton, and each will evolve to itsthe availability and use of radiographic reports. own best design.24 The perfect solution willIn a ®lm-based environment, a conversation (in be a symbiosis of hardware and software thatperson or by phone) is the quickest and most will do nothing that couldnt have been donecommon way of getting a radiographic report. before, except that is does it right.The use of a digital dictation system is not asecient because of delays before the formalreports become available. Sometimes the radi- FUTURE DIRECTIONSologists will provide ``we read, either by faxingpreliminary reports to the ICU or by attaching Image distribution and simultaneous accessa note to the radiological examination. to images represent major advantages of PACS, In a digital environment, the availability of and they lay o€ the foundation for teleradiol-reports can be improved by providing PACS ogy and cooperative interpretation. Such fea-and workstation support for soft-copy prelimi- tures allow the ICU physician to remain withinnary reports in the form of audio voice clips the ICU and still bene®t from real-time con-attached to every reported examination. sultation with a radiologist. The OSIRIS pro-Whenever report dictation is done through ject used the HERMES protocol for master/voice recognition, automatic text string searches slave synchronization of remote workstation.25should be used for the detection of high-risk Bellon et al. described a system based on Javasclinical problems2 and also for the detection of ``Web PC paradigm, which used applets for``synopsis for the radiographic ®ndings. When synchronization.26 The importance of remotead hoc diagnosis entry or ``canned reports can consultation with a specialist is acknowledgedbe used, the transcription phase can be skipped by the ongoing e€ort of the Digital Imaging andentirely, thus greatly improving report turn- Communication in Medicine Workgroup 11 toaround times. standardize the collaboration mode. Advances in teleradiology, coupled with THIS IS THE QUESTION technological advances for hardware portability and faster wireless transmission, will allow ex- Is it better to build one radiology workstation cellent report turnaround times. Desktop-re-that works ``OK for many modalities (CT/ placement high-performance notebooks, withMR, CR, Ultrasound, and Nuclear Medicine) 1600 ´ 1200 pixel LCD screens, are now avail-and many classes of users (radiologists, ICU able and a€ordable. Mobile computing devicesphysicians, referring physicians, surgeons, and such as the IBM ThinkPad TransNote or theresidents) or to build several digital viewers, Tablet PC could help the radiologist to hand-each of which excels in only a speci®c environ- write a wet report, and then send the digitalment? notes to the ICU sta€ through a fast wireless An all-inclusive solution (``workhorse22 connection.workstation) provides ¯exibility, power, andcost-saving bene®ts. Still, we think we must be ACKNOWLEDGMENTSable to peel away the unnecessary functionalityfrom a multipurpose workstation, tailoring it to The authors are grateful to the Canada Natural andindividual departments and user types. We pro- Engineering Research Council for funding this research.
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