Update on PACS,Update on PACS,
Radiology Informatics,Radiology Informatics,
and Workflowand Workflow
Paul J. Chang, M.D., ...
Speaker DisclosureSpeaker Disclosure
CoCo--founderfounder –– Stentor (acquired by Philips)Stentor (acquired by Philips)
Me...
ChallengesChallenges
Advances in data acquisition technologyAdvances in data acquisition technology
Increased treatment op...
Present and Near Future RealitiesPresent and Near Future Realities
““Do more in less time with greaterDo more in less time...
PACS InfrastructurePACS Infrastructure
NetworkNetwork
ArchiveArchive
Modality InterfaceModality Interface
RIS InterfaceRIS...
PACS Infrastructure: TrendsPACS Infrastructure: Trends
Networks:
More capable, ubiquitous, and integrated
Increased use of...
““The target always movesThe target always moves…”…”
Advances in data acquisition technology create massive and
complex da...
““The maturation of digital imageThe maturation of digital image
managementmanagement””
Electronic image management within...
Radiology Informatics and WorkflowRadiology Informatics and Workflow
ChallengesChallenges
Large image dataset managementLa...
Large Image Dataset ManagementLarge Image Dataset Management
An Informatics ChallengeAn Informatics Challenge
Use of large image datasets with advanced
visualization has demonstrated ...
Informatics ChallengesInformatics Challenges
Archive ArchitectureArchive Architecture
ServerServer--Client Data Transmissi...
Informatics ChallengesInformatics Challenges
Archive ArchitectureArchive Architecture
ServerServer--Client Data Transmissi...
Archive Architecture: Current TrendsArchive Architecture: Current Trends
Trend towards on-demand (“spinning”) archive desi...
Archive ModelsArchive Models
SelectiveSelective
Selective with temporary cacheSelective with temporary cache
Complete data...
““SelectiveSelective”” Archival ModelArchival Model
Modality
PACS
Archive
“Traditional”
PACS Workstation
3D / Advanced
Vis...
““SelectiveSelective”” Archival ModelArchival Model
Advantages:Advantages:
Permanently storing only “thick slices” least d...
““SelectiveSelective”” Archival Model with TemporaryArchival Model with Temporary
CacheCache
Modality
PACS
Archive
“Tradit...
““SelectiveSelective”” Archival Model withArchival Model with
Temporary CacheTemporary Cache
Advantages:Advantages:
Perman...
““Complete DatasetComplete Dataset””
Archival ModelArchival Model
Modality
PACS
Archive
“Traditional”
PACS Workstation
3D ...
““Complete DatasetComplete Dataset”” Archival ModelArchival Model
Advantages:Advantages:
Permanently storing both thick an...
““SelectiveSelective”” Archival Model with IntelligentArchival Model with Intelligent
DICOM Router / CacheDICOM Router / C...
““SelectiveSelective”” Archival Model withArchival Model with
Intelligent DICOM Router / CacheIntelligent DICOM Router / C...
““Complete DatasetComplete Dataset”” Archival Model withArchival Model with
““PseudoPseudo--IntegratedIntegrated”” Worksta...
““Complete DatasetComplete Dataset”” Archival Model withArchival Model with
““PseudoPseudo--IntegratedIntegrated”” Worksta...
““Complete DatasetComplete Dataset”” Archival Model withArchival Model with
““IntegratedIntegrated”” WorkstationWorkstatio...
““Complete DatasetComplete Dataset”” Archival Model withArchival Model with
““IntegratedIntegrated”” WorkstationWorkstatio...
““Complete DatasetComplete Dataset”” Archival Model withArchival Model with
““ServerServer--Thin ClientThin Client”” Commu...
““Complete DatasetComplete Dataset”” Archival Model withArchival Model with
““ServerServer--Thin ClientThin Client”” Commu...
ServerServer--Client Data TransmissionClient Data Transmission
Transmission of “thin slice” datasets from PACS archive
ser...
Visualization ToolsVisualization Tools
Tools must be seamlessly integrated into “routine” workflow
(“just like window/leve...
Workflow ModelsWorkflow Models
Must be seamlessly integrated into overall
departmental workflow (not “out of band”)
Integr...
Maximizing Productivity byMaximizing Productivity by
Optimizing InformationOptimizing Information
Throughput in RadiologyT...
Why Increase Productivity andWhy Increase Productivity and
Efficiency in Radiology?Efficiency in Radiology?
Decreased dela...
Barriers to Efficiency in RadiologyBarriers to Efficiency in Radiology
Workflow based on film and paper informationWorkflo...
An Approach to Improve Efficiency inAn Approach to Improve Efficiency in
RadiologyRadiology
ImprovedImproved patientpatien...
RequirementsRequirements
Must get rid of film and paperMust get rid of film and paper
Electronic based informatics systems...
PACS is just the first stepPACS is just the first step……
Getting rid of film (and filming) is an important firstGetting ri...
ReRe--Engineering TechnologistEngineering Technologist
Workflow to Increase EfficiencyWorkflow to Increase Efficiency
Technologist Workflow:Technologist Workflow:
Performed Procedure with Context SpecificationPerformed Procedure with Contex...
Automated Exception HandlerAutomated Exception Handler
Automated Exception HandlerAutomated Exception Handler
Automated Exception HandlerAutomated Exception Handler
Automated Exception HandlerAutomated Exception Handler
ReRe--Engineering RadiologistEngineering Radiologist
Workflow to Improve EfficiencyWorkflow to Improve Efficiency
Integrated Dictation / Speech RecognitionIntegrated Dictation / Speech Recognition
““Find PhysicianFind Physician””
““Find PhysicianFind Physician””
Clinical DashboardClinical Dashboard
Clinical DashboardClinical Dashboard
22.5 hrs
24.3 hrs
17.7 hrs*
24% reduction
*p < .001
Improved Report Turnaround TimeImproved Report Turnaround Time
with Da...
PACS Admin User InterfacePACS Admin User Interface
The Radiology Dashboard :The Radiology Dashboard :
Delinquent Undictated CasesDelinquent Undictated Cases
The Radiology Dashboard :The Radiology Dashboard :
Delinquent Undictated CasesDelinquent Undictated Cases
Improved False Dictation TurnaroundImproved False Dictation Turnaround
with Dashboardwith Dashboard
Division Pre Post
Abdo...
Supporting Clinician WorkflowSupporting Clinician Workflow
Advanced ClinicianAdvanced Clinician WorkflowWorkflow
Optimized image presentation, worklistsOptimized image presentation,...
Prioritized Report ListPrioritized Report List
Prioritized Report ListPrioritized Report List
With permission from Amirsys, Inc
Results at UPMCResults at UPMC
1.3 million studies / year1.3 million studies / year
CT in Abdominal Imaging:CT in Abdomina...
What is Needed?What is Needed?
Better coordination with other servicesBetter coordination with other services
(nursing, tr...
Integration and InteroperabilityIntegration and Interoperability
ModelsModels
The Holy Grail:The Holy Grail:
The Multimedia EnabledThe Multimedia Enabled
Electronic Medical RecordElectronic Medical Re...
The PACSThe PACS –– RIS Workflow IntegrationRIS Workflow Integration
Model is not sufficient!Model is not sufficient!
Radi...
Advanced Integration ApproachesAdvanced Integration Approaches
IHE (DICOM, HL7)IHE (DICOM, HL7)
Distributed Object toolsDi...
Typical LegacyTypical Legacy--based IT Environment:based IT Environment:
““Using humans to integrate workflowUsing humans ...
Integration using aIntegration using a
““Single Vendor SolutionSingle Vendor Solution””
Single Vendor Application “Suite”
...
Using “Edge” Protocols (DICOM & HL7) to
Orchestrate Integrated Workflow:
IHE PACS – RIS Integration Workflow Model
RIS PAC...
Limitations of Current IHELimitations of Current IHE
““Edge ProtocolEdge Protocol”” ApproachesApproaches
OK for relatively...
Limitations of Vendor IntegrationLimitations of Vendor Integration
Offerings:Offerings:
Inability to provide optimized / c...
Enterprise Integration Model:Enterprise Integration Model:
Towards a Service Oriented ArchitectureTowards a Service Orient...
Service Oriented Architecture (SOA)Service Oriented Architecture (SOA)
Component based architecture that supportsComponent...
Challenges to Integration:Challenges to Integration:
Architecture specification very challengingArchitecture specification...
RelativeRelative ““ValueValue”” Proposition ofProposition of
Software vs. Domain KnowledgeSoftware vs. Domain Knowledge
Ti...
Summary:Summary:
Modern Digital Management Requirements:Modern Digital Management Requirements:
Significant improvements h...
It is no longer just about film savings;
PACS must also result in
significant improvements in
FTE productivity, efficiency...
It is no longer just about images;
PACS solutions must “complete” the informatics cycle
by providing up to
“near real-time...
It is no longer just about radiology;
the future is not about a
$40K PACS workstation
that just displays radiology images;...
It is not just about hardware and software;
we must be willing to “re-engineer” ourselves in order to
fully leverage these...
Update on PACS, Radiology Informatics, and Workflow
Update on PACS, Radiology Informatics, and Workflow
Update on PACS, Radiology Informatics, and Workflow
Update on PACS, Radiology Informatics, and Workflow
Update on PACS, Radiology Informatics, and Workflow
Update on PACS, Radiology Informatics, and Workflow
Update on PACS, Radiology Informatics, and Workflow
Update on PACS, Radiology Informatics, and Workflow
Update on PACS, Radiology Informatics, and Workflow
Update on PACS, Radiology Informatics, and Workflow
Update on PACS, Radiology Informatics, and Workflow
Update on PACS, Radiology Informatics, and Workflow
Update on PACS, Radiology Informatics, and Workflow
Update on PACS, Radiology Informatics, and Workflow
Update on PACS, Radiology Informatics, and Workflow
Update on PACS, Radiology Informatics, and Workflow
Update on PACS, Radiology Informatics, and Workflow
Update on PACS, Radiology Informatics, and Workflow
Update on PACS, Radiology Informatics, and Workflow
Update on PACS, Radiology Informatics, and Workflow
Update on PACS, Radiology Informatics, and Workflow
Update on PACS, Radiology Informatics, and Workflow
Update on PACS, Radiology Informatics, and Workflow
Update on PACS, Radiology Informatics, and Workflow
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Update on PACS, Radiology Informatics, and Workflow

  1. 1. Update on PACS,Update on PACS, Radiology Informatics,Radiology Informatics, and Workflowand Workflow Paul J. Chang, M.D., FSIIMPaul J. Chang, M.D., FSIIM Professor & ViceProfessor & Vice--Chairman, Radiology InformaticsChairman, Radiology Informatics Medical Director, Pathology InformaticsMedical Director, Pathology Informatics University of Chicago School of MedicineUniversity of Chicago School of Medicine Medical Director, Enterprise ImagingMedical Director, Enterprise Imaging University of Chicago HospitalsUniversity of Chicago Hospitals
  2. 2. Speaker DisclosureSpeaker Disclosure CoCo--founderfounder –– Stentor (acquired by Philips)Stentor (acquired by Philips) Medical/Technical Advisory Boards:Medical/Technical Advisory Boards: PhilipsPhilips AmirsysAmirsys Poiesis InformaticsPoiesis Informatics MEDIAN TechnologiesMEDIAN Technologies Visage ImagingVisage Imaging Vital ImagesVital Images Grants and contractsGrants and contracts -- NIH, NLM, DARPANIH, NLM, DARPA Air Force, SCAR/SIIMAir Force, SCAR/SIIM
  3. 3. ChallengesChallenges Advances in data acquisition technologyAdvances in data acquisition technology Increased treatment options and complexityIncreased treatment options and complexity Health care enterprise is becoming increasinglyHealth care enterprise is becoming increasingly complexcomplex Significantly increased user expectations andSignificantly increased user expectations and requirementsrequirements External and economic constraints significantExternal and economic constraints significant
  4. 4. Present and Near Future RealitiesPresent and Near Future Realities ““Do more in less time with greaterDo more in less time with greater constraints in a more complex distributedconstraints in a more complex distributed environmentenvironment”” ““Film and paper no longer workFilm and paper no longer work”” Digital based informatics solutions inevitableDigital based informatics solutions inevitable
  5. 5. PACS InfrastructurePACS Infrastructure NetworkNetwork ArchiveArchive Modality InterfaceModality Interface RIS InterfaceRIS Interface WorkstationsWorkstations Operational SupportOperational Support
  6. 6. PACS Infrastructure: TrendsPACS Infrastructure: Trends Networks: More capable, ubiquitous, and integrated Increased use of wireless Archive: Less dependence on hierarchical models More capable and cost effective options (NAS, SAN) Trend towards on demand performance; less dependence on prefetch models Better integration models (IHE, web services, CCOW, etc); less dependence on RIS-PACS broker agents Workstations: Significantly more capable, affordable Trend towards web based thin clients Modern PACS offerings are more capable and affordable;Modern PACS offerings are more capable and affordable; however, expectations and requirements have alsohowever, expectations and requirements have also significantly increasedsignificantly increased
  7. 7. ““The target always movesThe target always moves…”…” Advances in data acquisition technology create massive and complex datasets “Do more in less time with greater constraints in a more complex distributed environment” – “real time hyper-efficient radiology” Absolute requirement for truly comprehensive enterprise image distribution strategy - “radiologists aren’t the only ones who need images” Support for non-radiology image data Cardiology Visible light (pathology, dermatology, endoscopy, ophthalmology, etc.) Integration into electronic health record (EHR)
  8. 8. ““The maturation of digital imageThe maturation of digital image managementmanagement”” Electronic image management within the radiology department is no longer a daunting task “PACS is nothing…” Today’s challenge: “fully leveraged electronic based workflow and practice management” that can support today’s more complex requirements The real goal: measurable improvements in efficiency, productivity, cost-effectiveness, accuracy, and patient outcome. Modern digital image management workflow must support the radiologist value innovator
  9. 9. Radiology Informatics and WorkflowRadiology Informatics and Workflow ChallengesChallenges Large image dataset managementLarge image dataset management Maximizing productivity by optimizing informationMaximizing productivity by optimizing information throughput in radiologythroughput in radiology Integration and interoperability models to supportIntegration and interoperability models to support advanced workflowadvanced workflow Enhanced communication and collaborationEnhanced communication and collaboration
  10. 10. Large Image Dataset ManagementLarge Image Dataset Management
  11. 11. An Informatics ChallengeAn Informatics Challenge Use of large image datasets with advanced visualization has demonstrated great clinical utility Adoption of digital based image management (PACS) inevitable Proportion of near-isotropic image datasets will continue to significantly increase Presents a non-trivial data management and informatics challenge
  12. 12. Informatics ChallengesInformatics Challenges Archive ArchitectureArchive Architecture ServerServer--Client Data TransmissionClient Data Transmission Visualization ToolsVisualization Tools Workflow ModelsWorkflow Models
  13. 13. Informatics ChallengesInformatics Challenges Archive ArchitectureArchive Architecture ServerServer--Client Data TransmissionClient Data Transmission Visualization ToolsVisualization Tools Workflow ModelsWorkflow Models
  14. 14. Archive Architecture: Current TrendsArchive Architecture: Current Trends Trend towards on-demand (“spinning”) archive designs (less emphasis on hierarchical storage models) Penalty for migration of very large datasets from slower media increasingly unacceptable Unpredictable and on-demand study retrieval requirements from enterprise users Current and even near future storage requirements for large image datasets track reasonably well with continuously improving technical and economic efficiencies related to mass storage These trends have significantly influenced archive persistence models for large image datasets The challenge is not storage, but image transmission
  15. 15. Archive ModelsArchive Models SelectiveSelective Selective with temporary cacheSelective with temporary cache Complete datasetComplete dataset Selective with intelligent DICOM router / cacheSelective with intelligent DICOM router / cache Complete dataset withComplete dataset with ““pseudopseudo”” integrated workstationintegrated workstation Complete dataset with integrated workstationComplete dataset with integrated workstation Complete dataset withComplete dataset with ““serverserver--thin clientthin client”” communicationcommunication Variationsofthese m odelsexist
  16. 16. ““SelectiveSelective”” Archival ModelArchival Model Modality PACS Archive “Traditional” PACS Workstation 3D / Advanced Visualization Workstation “Thick Slices” (DICOM) “Thick Slices” (DICOM) (DICOM) Selected Images Video Clips (“Key Images”) “Thin Slices” (DICOM) (Manual or Automatic)
  17. 17. ““SelectiveSelective”” Archival ModelArchival Model Advantages:Advantages: Permanently storing only “thick slices” least demanding on PACS archive storage requirements Trivial to implement Disadvantages:Disadvantages: Not able to use interactive advanced visualization on prior or even relatively recent studies (only stored “key images” are available) Not able to take full advantage of future visualization and analysis tools on prior studies Generating and transmission of separate thin slices may be labor intensive and disruptive to normal workflow (especially if requirement for thin slices not anticipated) Modality not suited to scalable DICOM SCU to multiple destinations
  18. 18. ““SelectiveSelective”” Archival Model with TemporaryArchival Model with Temporary CacheCache Modality PACS Archive “Traditional” PACS Workstation 3D / Advanced Visualization Workstation “Thick Slices” (DICOM) “Thick Slices” (DICOM) (DICOM) Selected Images Video Clips (“Key Images”) Temp Cache “Thin Slices” (DICOM ) “Thin Slices” (DICOM)
  19. 19. ““SelectiveSelective”” Archival Model withArchival Model with Temporary CacheTemporary Cache Advantages:Advantages: Permanently storing only “thick slices” least demanding on PACS archive storage requirements Allows use of interactive advanced visualization on all current and relatively recent prior studies (depending on size of temporary cache) Generation and transmission of thin slices can be automated Disadvantages:Disadvantages: Not able to use interactive advanced visualization on prior studies no longer resident in the temporary cache Not able to take full advantage of future visualization and analysis tools on prior studies no longer resident in the temporary cache
  20. 20. ““Complete DatasetComplete Dataset”” Archival ModelArchival Model Modality PACS Archive “Traditional” PACS Workstation 3D / Advanced Visualization Workstation “Thick and Thin Slices” (DICOM) “Thick Slices” (DICOM) (DICOM) Selected Images Video Clips (“Key Images”) “Thin Slices” (DICOM)
  21. 21. ““Complete DatasetComplete Dataset”” Archival ModelArchival Model Advantages:Advantages: Permanently storing both thick and thin slices allows advanced visualization on all current and prior studies Generation and transmission of thin slices can be automated Disadvantages:Disadvantages: Greatly increases PACS archive permanent storage requirements PACS archives tend to have poor SCU performance, especially with respect to scalability Storing both thick and thin slices within PACS archive wasteful and redundant
  22. 22. ““SelectiveSelective”” Archival Model with IntelligentArchival Model with Intelligent DICOM Router / CacheDICOM Router / Cache Modality PACS Archive “Traditional” PACS Workstation 3D / Advanced Visualization Workstation “Thick and Thin Slices” (DICOM) “Thick Slices” (DICOM) 3D / Advanced Visualization Workstation 3D / Advanced Visualization Workstation “Thin Slices” (DICOM) DICOM Router Cache (HL7, Web Services, etc.)
  23. 23. ““SelectiveSelective”” Archival Model withArchival Model with Intelligent DICOM Router / CacheIntelligent DICOM Router / Cache Advantages:Advantages: Permanently storing only “thick slices” least demanding on PACS archive storage requirements Allows use of interactive advanced visualization on all current and relatively recent prior studies (depending on size of temporary cache) Improves efficiency and scalability of thin slice DICOM image transmission; reduces burden to modality and PACS Generation and transmission of thin slices can be automated Disadvantages:Disadvantages: Not able to use interactive advanced visualization on prior studies no longer resident in the temporary cache Not able to take full advantage of future visualization and analysis tools on prior studies no longer resident in the temporary cache
  24. 24. ““Complete DatasetComplete Dataset”” Archival Model withArchival Model with ““PseudoPseudo--IntegratedIntegrated”” Workstation (Workstation (““PlugPlug--inin””)) Modality PACS Archive “Thick and Thin Slices” (DICOM) “Thick and Thin Slices” (DICOM) “Traditional” PACS Workstation 3D / Advanced Visualization “Plug-in” “Pseudo-Integrated Workstation” Selected Images Video Clips (“Key Images”)
  25. 25. ““Complete DatasetComplete Dataset”” Archival Model withArchival Model with ““PseudoPseudo--IntegratedIntegrated”” Workstation (Workstation (““PlugPlug--inin””)) Advantages:Advantages: Permanently storing both thick and thin slices allows advanced visualization on all current and prior studies Generation and transmission of thin slices can be automated Availability of advanced visualization tools via “plug-in” convenient and less disruptive to normal workflow Disadvantages:Disadvantages: Greatly increases PACS archive permanent storage requirements PACS archives tend to have poor SCU performance, especially with respect to scalability Storing both thick and thin slices within PACS archive wasteful and redundant
  26. 26. ““Complete DatasetComplete Dataset”” Archival Model withArchival Model with ““IntegratedIntegrated”” WorkstationWorkstation Modality PACS Archive “Thin Slices” (DICOM) “Thin Slices” (DICOM) “Traditional” PACS Workstation Tools 3D / Advanced Visualization Tools “Integrated Workstation” Selected Images Video Clips (“Key Images”)
  27. 27. ““Complete DatasetComplete Dataset”” Archival Model withArchival Model with ““IntegratedIntegrated”” WorkstationWorkstation Advantages:Advantages: Permanently storing thin slices allows advanced visualization on all current and prior studies Generation and transmission of thin slices can be automated Eliminates inefficiency of storing redundant thick slices Greatly reduces inefficient image data transmission Availability of advanced visualization tools integrated into PACS workstation convenient and less disruptive to normal workflow Disadvantages:Disadvantages: Greatly increases PACS archive permanent storage requirements PACS archives tend to have poor SCU performance, especially with respect to scalability
  28. 28. ““Complete DatasetComplete Dataset”” Archival Model withArchival Model with ““ServerServer--Thin ClientThin Client”” CommunicationCommunication Modality PACS Archive “Thin Slices” (DICOM) “Just in Time” or “Streaming” Server–Client Protocols “Traditional” PACS Workstation Tools 3D / Advanced Visualization Tools “Thin Client” Integrated Workstation(DICOM) Selected Images Video Clips (“Key Images”) 3D / Advanced Visualization Engine / Server * DICOM or Shared Architecture *
  29. 29. ““Complete DatasetComplete Dataset”” Archival Model withArchival Model with ““ServerServer--Thin ClientThin Client”” CommunicationCommunication Advantages:Advantages: Permanently storing thin slices allows advanced visualization on all current and prior studies Generation and transmission of thin slices can be automated Availability of advanced visualization tools integrated into PACS workstation convenient and less disruptive to normal workflow Server-thin client communication greatly reduces hardware and network requirements for PACS workstations Server-thin client model can greatly improve client performance Allows for full featured advanced visualization tools for web viewers Disadvantages:Disadvantages: Greatly increases PACS archive permanent storage requirements
  30. 30. ServerServer--Client Data TransmissionClient Data Transmission Transmission of “thin slice” datasets from PACS archive server to PACS workstation client via DICOM can be very time consuming and require significant network and client resources Trend towards server-thin client architecture: 3D / Advanced Visualization engine located server-side Engine usually has direct and efficient assess to PACS archive Server communicates to thin-client server via very efficient “just in time” or streaming mechanisms Can allow for very high client performance Much lower network and workstation resource requirements Can provide advanced visualization functionality to web clients
  31. 31. Visualization ToolsVisualization Tools Tools must be seamlessly integrated into “routine” workflow (“just like window/level, zoom/pan, etc.”) Advanced presentation and navigational tools must be available for current and prior studies simultaneously Requirement for user intensive editing and “setup” (ROI definition, segmentation, thresholding, etc.) must be significantly reduced (automated protocols should be clinically oriented and context-specific) Advanced visualization tools must be available to enterprise users (non-radiologists) via web clients
  32. 32. Workflow ModelsWorkflow Models Must be seamlessly integrated into overall departmental workflow (not “out of band”) Integrated functionality a must for both radiology workstations and enterprise web clients (“master worklist’) Integration with computerized order entry (CPOE) and protocol tools – will greatly reduce user editing / setup requirement
  33. 33. Maximizing Productivity byMaximizing Productivity by Optimizing InformationOptimizing Information Throughput in RadiologyThroughput in Radiology
  34. 34. Why Increase Productivity andWhy Increase Productivity and Efficiency in Radiology?Efficiency in Radiology? Decreased delay in diagnosisDecreased delay in diagnosis Decreased patient length of stayDecreased patient length of stay Reduce backlog of elective outpatient studiesReduce backlog of elective outpatient studies Maximize revenue generationMaximize revenue generation Improve patient satisfactionImprove patient satisfaction
  35. 35. Barriers to Efficiency in RadiologyBarriers to Efficiency in Radiology Workflow based on film and paper informationWorkflow based on film and paper information deliverydelivery Excessive time spent onExcessive time spent on ““peripheralperipheral”” taskstasks InflexibleInflexible ““serializedserialized”” workflow modelworkflow model Film and paper are used as informationFilm and paper are used as information ““batonsbatons”” passed between technologist and radiologistpassed between technologist and radiologist Does not scale to large and distributed practicesDoes not scale to large and distributed practices Shortsighted perspective re: enablingShortsighted perspective re: enabling ““lubricationlubrication”” FTEFTE
  36. 36. An Approach to Improve Efficiency inAn Approach to Improve Efficiency in RadiologyRadiology ImprovedImproved patientpatient throughput is not sufficient; improvedthroughput is not sufficient; improved informationinformation throughput is the real goalthroughput is the real goal Must eliminate or minimizeMust eliminate or minimize ““peripheralperipheral”” taskstasks Informatics goal: to sever theInformatics goal: to sever the ““hardhard--linkagelinkage”” betweenbetween technologist workflow and radiologist workflowtechnologist workflow and radiologist workflow Must change from serialized workflow model toMust change from serialized workflow model to asynchronousasynchronous ““parallelparallel”” modelmodel
  37. 37. RequirementsRequirements Must get rid of film and paperMust get rid of film and paper Electronic based informatics systems areElectronic based informatics systems are requiredrequired Tighter integration of electronic informationTighter integration of electronic information systems requiredsystems required Must reMust re--engineer all workflow processes toengineer all workflow processes to maximally leverage electronic infrastructuremaximally leverage electronic infrastructure
  38. 38. PACS is just the first stepPACS is just the first step…… Getting rid of film (and filming) is an important firstGetting rid of film (and filming) is an important first stepstep However, one must also get rid ofHowever, one must also get rid of paperpaper (the(the ““otherother”” information baton)information baton) This can be very challenging: the paper requisitionThis can be very challenging: the paper requisition serves many workflow functionsserves many workflow functions Informs the radiologist that a study needs to beInforms the radiologist that a study needs to be interpretedinterpreted Contains clinical information / contextContains clinical information / context Frequently serves as the interface to the dictation systemFrequently serves as the interface to the dictation system
  39. 39. ReRe--Engineering TechnologistEngineering Technologist Workflow to Increase EfficiencyWorkflow to Increase Efficiency
  40. 40. Technologist Workflow:Technologist Workflow: Performed Procedure with Context SpecificationPerformed Procedure with Context Specification
  41. 41. Automated Exception HandlerAutomated Exception Handler
  42. 42. Automated Exception HandlerAutomated Exception Handler
  43. 43. Automated Exception HandlerAutomated Exception Handler
  44. 44. Automated Exception HandlerAutomated Exception Handler
  45. 45. ReRe--Engineering RadiologistEngineering Radiologist Workflow to Improve EfficiencyWorkflow to Improve Efficiency
  46. 46. Integrated Dictation / Speech RecognitionIntegrated Dictation / Speech Recognition
  47. 47. ““Find PhysicianFind Physician””
  48. 48. ““Find PhysicianFind Physician””
  49. 49. Clinical DashboardClinical Dashboard
  50. 50. Clinical DashboardClinical Dashboard
  51. 51. 22.5 hrs 24.3 hrs 17.7 hrs* 24% reduction *p < .001 Improved Report Turnaround TimeImproved Report Turnaround Time with Dashboardwith Dashboard
  52. 52. PACS Admin User InterfacePACS Admin User Interface
  53. 53. The Radiology Dashboard :The Radiology Dashboard : Delinquent Undictated CasesDelinquent Undictated Cases
  54. 54. The Radiology Dashboard :The Radiology Dashboard : Delinquent Undictated CasesDelinquent Undictated Cases
  55. 55. Improved False Dictation TurnaroundImproved False Dictation Turnaround with Dashboardwith Dashboard Division Pre Post Abdominal 10 0 MSK 26 0 Neuro 13 0 Chest 0 0 Total 49 / 33,077 0* / 36,958 (0.15%) (0%) *p < .001 Prevalence of “C-Status” Dictations (>72h)
  56. 56. Supporting Clinician WorkflowSupporting Clinician Workflow
  57. 57. Advanced ClinicianAdvanced Clinician WorkflowWorkflow Optimized image presentation, worklistsOptimized image presentation, worklists Physician Order Entry and SchedulingPhysician Order Entry and Scheduling (with Decision Support)(with Decision Support) MultimediaMultimedia--enhanced web reportsenhanced web reports Asynchronous and synchronousAsynchronous and synchronous collaboration toolscollaboration tools Context sharing with EMRContext sharing with EMR
  58. 58. Prioritized Report ListPrioritized Report List
  59. 59. Prioritized Report ListPrioritized Report List
  60. 60. With permission from Amirsys, Inc
  61. 61. Results at UPMCResults at UPMC 1.3 million studies / year1.3 million studies / year CT in Abdominal Imaging:CT in Abdominal Imaging: Study throughput increased by 54% when PACSStudy throughput increased by 54% when PACS institutedinstituted ThroughputThroughput doubleddoubled when enterprise image distributionwhen enterprise image distribution deployed and paper requisitions eliminated.deployed and paper requisitions eliminated. $5.8 million saved per year in film and distribution$5.8 million saved per year in film and distribution costscosts
  62. 62. What is Needed?What is Needed? Better coordination with other servicesBetter coordination with other services (nursing, transport)(nursing, transport) Intelligent ordering and schedulingIntelligent ordering and scheduling Electronic study protocol selection withElectronic study protocol selection with access to RIS and CISaccess to RIS and CIS Electronic positive patient ID (PPI) withElectronic positive patient ID (PPI) with integration with modality worklist and RISintegration with modality worklist and RIS Integration of modalities with RIS/PACSIntegration of modalities with RIS/PACS
  63. 63. Integration and InteroperabilityIntegration and Interoperability ModelsModels
  64. 64. The Holy Grail:The Holy Grail: The Multimedia EnabledThe Multimedia Enabled Electronic Medical RecordElectronic Medical Record (with Synchronous and(with Synchronous and Asynchronous Collaboration)Asynchronous Collaboration)
  65. 65. The PACSThe PACS –– RIS Workflow IntegrationRIS Workflow Integration Model is not sufficient!Model is not sufficient! RadiologyRadiology--centric, imagecentric, image--centric perspectivecentric perspective IHE is an improvement butIHE is an improvement but…… Truly valuable workflow enhancement can only beTruly valuable workflow enhancement can only be achieved if a true enterprise perspective is used withachieved if a true enterprise perspective is used with respect to integrationrespect to integration Requires a more flexible integration workflow modelRequires a more flexible integration workflow model
  66. 66. Advanced Integration ApproachesAdvanced Integration Approaches IHE (DICOM, HL7)IHE (DICOM, HL7) Distributed Object toolsDistributed Object tools CORBACORBA JAVAJAVA ActiveXActiveX Web Services,Web Services, Service Oriented Architecture (SOA)Service Oriented Architecture (SOA)
  67. 67. Typical LegacyTypical Legacy--based IT Environment:based IT Environment: ““Using humans to integrate workflowUsing humans to integrate workflow”” Patient EHR RIS PACSPath
  68. 68. Integration using aIntegration using a ““Single Vendor SolutionSingle Vendor Solution”” Single Vendor Application “Suite” Path ModuleRIS ModuleEHR Module PACS Module
  69. 69. Using “Edge” Protocols (DICOM & HL7) to Orchestrate Integrated Workflow: IHE PACS – RIS Integration Workflow Model RIS PACS Scheduled Prefetch Report Prefetch Demographic / ADT Update Study Validation Dictated Status Worklist Update Modality Modality Worklist Modality Performed Procedure Dictation Reporting Storage Commit Performed Procedure Performed Procedure Dictated Status Update Storage Commit DICOM HL7 HL7 DICOM DICOM
  70. 70. Limitations of Current IHELimitations of Current IHE ““Edge ProtocolEdge Protocol”” ApproachesApproaches OK for relatively few actorsOK for relatively few actors PointPoint--toto--point messaging approach challenging to scalepoint messaging approach challenging to scale and manage beyond 2and manage beyond 2--4 actors4 actors ““Everyone has to be on the same pageEveryone has to be on the same page”” ““Cookie cutter vs OptimizationCookie cutter vs Optimization”” Needs more flexible and powerful workflow / businessNeeds more flexible and powerful workflow / business logiclogic orchestrationorchestration
  71. 71. Limitations of Vendor IntegrationLimitations of Vendor Integration Offerings:Offerings: Inability to provide optimized / customized solutions for specific workflow domains (“one size fits all”) Delay in responding to changing priorities and user functional specifications Proposed solution: a more flexible, capable, and scalableProposed solution: a more flexible, capable, and scalable architecture coupled with a more agile software developmentarchitecture coupled with a more agile software development methodologymethodology
  72. 72. Enterprise Integration Model:Enterprise Integration Model: Towards a Service Oriented ArchitectureTowards a Service Oriented Architecture Pathology HIS PACSRIS Middle (“Business Logic”) Layer (Agents, ORBs, Web Services, etc.)
  73. 73. Service Oriented Architecture (SOA)Service Oriented Architecture (SOA) Component based architecture that supportsComponent based architecture that supports ““compositecomposite”” applications by orchestrating loosely coupledapplications by orchestrating loosely coupled ““servicesservices”” Transition fromTransition from ““hard linkedhard linked”” data and presentation state todata and presentation state to ““loosely coupledloosely coupled”” services:services: Universally exposableUniversally exposable Universally selfUniversally self--describingdescribing Universally consumableUniversally consumable Services areServices are ““orchestratedorchestrated”” to create optimizedto create optimized ““compositecomposite”” useruser ““experienceexperience””
  74. 74. Challenges to Integration:Challenges to Integration: Architecture specification very challengingArchitecture specification very challenging (What is the(What is the ““business model?business model?””)) Common semantic and vocabulary models immature:Common semantic and vocabulary models immature: SNOWMED, RadLex, ICD, UMLS, HLSNOWMED, RadLex, ICD, UMLS, HL--7 extensions, etc.7 extensions, etc. Probably not yet ready for prime timeProbably not yet ready for prime time Ontologies are still not ready forOntologies are still not ready for ““prime timeprime time”” Master person identification and authenticationMaster person identification and authentication ((““single logonsingle logon””)) SecuritySecurity Requires exposure to vendor database schema and interfacesRequires exposure to vendor database schema and interfaces Potential threat to current vendor marketing approachPotential threat to current vendor marketing approach Very difficult to accomplishVery difficult to accomplish
  75. 75. RelativeRelative ““ValueValue”” Proposition ofProposition of Software vs. Domain KnowledgeSoftware vs. Domain Knowledge Time “Value” Domain (Workflow) Knowledge Software Development
  76. 76. Summary:Summary: Modern Digital Management Requirements:Modern Digital Management Requirements: Significant improvements have been made with respect to PACS technology However, expectations and requirements have increased PACS infrastructure must now be able to address the complex workflow demands of the modern health care delivery system This will require significantly more powerful integration models and an enterprise perspective
  77. 77. It is no longer just about film savings; PACS must also result in significant improvements in FTE productivity, efficiency, and quality of service throughout the enterprise
  78. 78. It is no longer just about images; PACS solutions must “complete” the informatics cycle by providing up to “near real-time” image study interpretation and consultation in order to deliver true value. This requires getting rid of paper as well…
  79. 79. It is no longer just about radiology; the future is not about a $40K PACS workstation that just displays radiology images; the “holy grail” is the multimedia enabled electronic medical record with both synchronous and asynchronous collaboration functionality
  80. 80. It is not just about hardware and software; we must be willing to “re-engineer” ourselves in order to fully leverage these digital practice management systems. Technology is “easy,” changing human behavior and legacy workflow is much, much harder.

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