Radiology & Electronic Patient Record

 INTRODUCTION:

The staff at the Radiology Department at Galway University Hospitals had a vision in the mid 1990’s of where they wanted to be in regard to radiology patient pathways but were not exactly sure how they would get there.  Newly appointed Radiologists came with experience of electronic workflows from both the UK and the USA and combined with young enthusiastic administrative and radiographic staff, they championed the concept of automating what were paper-heavy, film and human resource dependent processes which were the norm for Ireland at that time.  The implementation of PAS (Patient Administration System) at University Hospital Galway in 1994 followed by a Radiology Ordercoms/Results module in 1997 introduced radiology staff and hospital clinicians to an electronic-based workflow for the first time.  Due to restricted system functionality of that first RIS, they were unable to remove paper from the workflow and of course film was still in use as this was pre-PACS in Ireland.  The news that PACS was transforming radiology workflow worldwide reached Galway and in 2004 a project team was set up involving key radiology staff, hospital clinicians, IT staff, medical physics, nursing and hospital management.  Their task was to seek an electronic solution for the paper-heavy and film-based radiology workflow for the region. Their aim was to work towards a "solution" (rather than purchase a bunch of "boxes") which would ensure a patient’s radiology data was available to authorized users Anytime, Anyplace, Anywhere with 99.8% uptime and to allow Clinicians place orders, receive and acknowledge results electronically.  After an EU procurement and tendering process, Galway University Hospitals selected Agfa Healthcare to provide the solution by means of a Managed Service contract into which they built refresh,upgrades and maintenance of system software and equipment. They also managed to replace a lot of end of life radiology equipment as part of this contract as all equipment needed to be PACS compatible. 

In November 2005 the first paperless/filmless radiology department in an Irish public hospital was born.  It has grown from strength to strength over the interim years.  Due to the system's ability to interoperate and integrate with other systems, the Galway University Hospitals and Roscommon have a robust interoperable electronic radiology record enabling a filmless/paperless workflow with which to serve their patients.  

Problem:

Paper dependent workflows:  Despite all hospital orders being placed on an electronic ordercoms from 1997 to 2005,  orders had to be printed at Radiology level so patients could be tracked through the scheduling, acquisition and reporting phase of the workflow.  Reports had to be printed and delivered to Referring Physicians both in-house and externally each day.

Film dependent workflows:  A film was only ever available in one place at a given time.  This introduced risk and a specific case of a delayed TB diagnosis, due to the fact that an unreported Chest x-ray film was removed from radiology and not returned for reporting until months later.  This was the catalyst to force the acquisition of an efficient RIS/PACS over the line.

Report turnaround time was often long due to the analogue process and was also heavily human resource dependent.  There were hundreds of studies being manually sorted, reports dictated on dictaphones, typed, signed off, printed and delivered daily to referring clinicians 

Manual processes: Hours were spent processing and sorting film.  Filing and retrieving film was cumbersome and time consuming.  Administrative staff spent hours typing dictations and filing and retrieving paper and film.

Patient tracking:  Large volume of enquiries by phone and in person to radiology about the status of in-patient orders and results.  Calls from patients and GP’s were also frequent due to delays in report turnaround time.

Results and Results acknowledgement:   It was difficult for Hospital Clinicians to track their patient’s results.  Hospital Clinicians placed hundreds of orders each week and needed a secure reliable method to check the order status and to receive results as they became available.  This was necessary to ensure the patient received appropriate follow up even if the result was normal.  Radiology had no way of knowing if results were received as there was no results acknowledgement facility in place

Access to data:  Accessing data when the patient moved cross site was difficult and time-consuming.  Extraction of data for management reports, although electronic was time consuming and reports took a long time to run and produce in a format suitable for analysis

Solution

For the purpose of demonstrating the solution, which is a full electronic radiology patient record, the following case study will outline the pathway of a sample patient of Galway University Hospitals and its healthcare partners.

Case Study (all names used are fictitious)

Padraig, a 67 year old male patient from North Donegal visits his GP for a check up and has a routine blood test which indicates a high PSA level.  He is referred to the Rapid Access Prostate Service (RAPS)  at Galway University Hospitals to be reviewed by a Consultant Urologist; Mr Waters. Padraig attends RAPS in Galway and using Mediweb (radiology EPR) Mr. Waters selects Padraig’s name from a list of patients registered to his clinic that day.  He places an order for an Ultrasound Transrectal Prostate Biopsy (TRUS).  Padraig goes to the Radiology Department where his TRUS is performed.  His electronic record is updated via RIS and images are transmitted to PACS. The staff in RAPS can track Padraig’s pathway through radiology on Mediweb and can see when his examination is finished and when he has left the department.   

The study is reported on RIS/PACS by the Consultant Radiologist using voice recognition, the report is immediately available to Mr Waters in his personal “My New Reports” folder on Mediweb. He accesses his reports on Mediweb daily and marks them as read.  Padraig’s  biopsy has been sent to the laboratory and Padraig returns home to Donegal.

Padraig is diagnosed with prostate cancer based on the results of his biopsy.  Mr. Waters receives the laboratory results at his office.  He logs on to Mediweb, brings up Padraig’s record and creates an order for an MRI Prostate scan and an Isotope Bone Scan to help him plan a pathway of care.  The MRI and Isotope Bone scan orders are vetted by a Radiologist on RIS and are given a high priority status.  High priority orders are accessed on RIS promptly by Radiology admin staff and early appointments are scheduled and sent to Padraig by post.  An SMS reminder for his appointments is  transmitted from RIS, days before his scheduled appointment.  Padraig travels to Galway the following week for his MRI Prostate and Bone Scan. Both exams are performed on the same day.

When reporting the MRI Prostate and Bone scan, the Radiologist issues an Unexpected and Clinically significant Result alert to Mr Waters, Consultant Urologist via the embedded RAD Alert system.  He wants to communicate the findings of bone metastases found on Padraig’s scan immediately.  Mr. Waters receives the RAD Alert notification to his smart phone.  He views the report on the App and accepts the Rad Alert.  The Radiologist gets a pop-up notification on his workstation confirming that Mr. Waters has accepted the alert and he is assured that Mr. Waters is aware of the significant findings.  Mr Waters, who is not on site when he receives the alert, logs in remotely to the PACS Xero Viewer (PACS web browser application) on his tablet and views Padraig’s images.  He arranges for Padraig’s case to be discussed at the next Multi disciplinary meeting.  Following discussion at that meeting it is decided that hormone treatment followed by radiotherapy will be recommended to Padraig.   Padraig agrees to have the hormone treatment at his local GP surgery and asks if his Radiotherapy can be performed in Altnagelvin Hospital, Derry as it is nearer to his home.  He says this will make it easier for him and his family.  

Attending Altnagelvin will reduce his journey time on treatment days from 7 hours to 40 mins.  Padraig gives consent for his radiology data to be made available to clinicians in Derry. Using Agfa’s Engage Suite for Integrated Care, Padraig’s radiology data from Galway and local hospital Letterkenny can be viewed in Derry by authorized users.  This allows his live radiology record, storing his most recent data be viewed by his treating clinicians.  If at any stage they require the data within their own Northern Ireland PACS (NIPACS), that data can be downloaded and stored locally with a simple click and store function.

Padraig had his hormone injections at his GP's surgery and his radiology data was assessed in Altnagelvin.  He will have his Radiotherapy treatment in Derry.  Padraig is very satisfied with the speedy care pathway from his initial visit to his GP right through to the recent offer to provide his radiotherapy treatment in Altnagelvin.   The interoperable electronic radiology record at Galway University Hospitals has facilitated this efficient workflow.  The vision held by staff in Galway in the mid-90’s has now come to fruition.   

Benefits:

•           Paperless and filmless workflows 
•           Access to patient data for authorized users; anytime, anyplace, anywhere  
•           Report turnaround time reduced significantly 
•           Automated workflow processes including results delivery and results acknowledgement
•           Patient and result tracking available for all relevant hospital staff
•           Electronic alerts for Referring Clinician gives a view of report on App
•           External sites can consume data without a need to move the data (safe and efficient)     
•           Easy retrieval of data for management reports, dashboards, analysis and research 

Next Steps:

Interoperate with NIMIS to allow image/report sharing across the Saolta Group and beyond

Integration with Electronic Document Management Record at GUH

Single sign-on for all systems

Integration with EPR

Written by 

Gina Naughton, RIS/PACS System Administrator and CCIO, Galway University Hospitals, Saolta Healthcare Group, gina.naughton@hse.ie, 

Acknowledgements & thanks to: 

RIS/PACS Team, Galway University Hospitals, Radiology Staff, Galway University Hospitals, Mr Garrett Durkan, Cons Urologist, GUH, RIS/PACS Team Letterkenny, IT Departments Galway and Letterkenny, Agfa Healthcare. Rivendale Systems Ltd, Cross Border Radiotherapy Project Team and the Office of CIO, HSE.