Regina O. Redfern

Radiology workflow and patient volume: Effect of picture archiving and communication systems on technologists and radiologists

This study was performed to evaluate the changes in workflow and efficiency in various clinical settings in the radiology department after the introduction of a picture archiving and communication system (PACS). Time and motion data were collected when conventional image management was used, and again after the introduction of a PACS. Changes in the elapsed time from examination request until the image dispatch to the radiologist, and from dispatch until report dictation, were evaluated. The relationship between patient volume and throughput was evaluated. The time from examination request until dispatch was significantly longer after the introduction of PACS for examinations taken on patients from the emergency department (ED) (pre-PACS, 20 minutes; post-PACS, 25 minutes;P<.0001), and for examinations taken on patients in the medical intensive care unit (MICU) (pre-PACS, 34 minutes; post-PACS, 42 minutes;P<.0001). The interval from image dispatch until report dictation shortened significantly after the introduction of PACS in the ED (pre-PACS, 38 minutes; post-PACS, 23 minutes;P<.0001) and in the outpatient department (OPD) (pre-PACS, 38 minutes; post-PACS, 20 minutes;P<.0001). Simple least squares regression showed a significant relationship between daily patient volume and the daily median time until report dictation (F=43.42,P<.001). PACS slowed technologists by prolonging the quality-control procedure. Radiologist workflow was shortened or not affected. Efficiency is dependent on patient volume, and workflow improvements are due to a shift from batch to on-line reading that is enabled by the ability of PACS to route enough examinations to keep radiologists fully occupied.

The effect of PACS on the time required for technologists to produce radiographic images in the emergency department radiology suite.

The purpose of this study was to evaluate the effect of a switch to a filmless image management system on the time required for technologists to produce radiographic images in the emergency department (ED) after controlling for exam difficulty and a variable workload. Time and motion data were collected on patients who had radiographic images taken while being treated in the emergency department over the 3½-year period from April 1997 to November 2000. Event times and demographic data were obtained from the radiology information system, from the hospital information system, from emergency department records, or by observation by research coordinators. Multiple least squares regression analysis identified several independent predictors of the time required for technologists to produce radiographic images. These variables included the level of technologist experience, the number of trauma-alert patient arrivals, and whether a filmless image management system was used (all P <.05). Our regression model explained 22% of the variability in technologist time (R2 Adjusted, 0.22; F = 24.01; P <.0001). The regression model predicted a time saving of 2 to 3 minutes per patient in the elapsed time from notification of a needed examination until image availability because of the implementation of PACS, a delay of 4 to 6 minutes per patient who were imaged by technologists who spent less than 10% of their work assignments within the ED, and a delay of 18 to 27 minutes in radiology workflow because of the arrival of a trauma alert patient. A filmless system decreased the amount of time required to produce radiographs. The arrival of a trauma alert patient delayed radiology workflow in the ED. Inexperienced technologists require 4 to 6 minutes of additional time per patient to complete the same amount of work accomplished by an experienced technologist.

A picture archival and communication system shortens delays in obtaining radiographic information in a medical intensive care unit.

Objective: To assess whether variables such as unit occupancy and aggregate severity of illness that reflect increased work demands on physicians in medical intensive care units (MICU) are associated with increased delays in their obtaining information about nonroutine chest radiographic examinations. To determine whether the presence of a picture archiving and communication system (PACS) workstation in the MICU shortens those delays. Design: A prospective cohort study stratified for presence or absence of PACS. Setting: MICU of a university hospital. Patients: A total of 118 patients admitted to the MICU who had nonroutine bedside chest radiographs. Measurements and Main Results: Multivariate analyses were conducted to determine how unit occupancy, patient acuity, the time of day the examination was taken, and the presence of a PACS workstation influenced the time from radiographic examination completion to the time when MICU physicians first obtained image information. In a multivariate analysis, patient acuity, unit occupancy, the aggregate level of severity of illness in the study cohort, whether the examination was taken at night or day, and the presence of a PACS workstation were significant predictors of the elapsed time from examination completion until review by MICU physicians. Without the PACS workstation, higher occupancy, higher aggregate severity of illness, and examinations taken during the day were associated with longer delays. Overall, the multivariate analysis showed a 24‐min decrease in the elapsed time to obtain information during periods with the PACS workstation compared with periods without the workstation (p = .03). Conclusions: A PACS workstation significantly decreased the delays in obtaining image information that occurred with high unit occupancy and high aggregate severity of illness and may improve unit efficiency under conditions of high physician workload.

Using a Web-Based Application to Enhance Resident Training and Improve Performance On-call

RATIONALE AND OBJECTIVES It is common practice in academic hospitals for radiology residents to provide preliminary interpretations for radiologic examinations performed in the emergency department (ED) during off-hours. In this study, we used a software program called Minerva to identify and track discrepancies between resident and faculty interpretation of ED studies. The objective was to determine if missed case conferences could reduce the number of resident discrepancies related to the types of cases reviewed. MATERIALS AND METHODS We used Minerva to identify and grade faculty-modified resident preliminary reports as minor or major discrepancies depending on whether the discrepancy had the potential to affect patient management or outcome. Minor and major discrepancy rates were calculated for all residents to evaluate call performance, establish benchmarks, and develop interventions to reduce the number of discrepant cases. RESULTS The total discrepancy rate for all residents (n = 22) was 2.6% with a standard deviation (SD) of 0.7%. The average major discrepancy rate for all residents was 1.1% with a SD of 0.4%. Trend analysis of missed cases was used to generate topic-specific resident missed case conferences on acromioclavicular joint separation injuries, elbow joint effusions, and osteochondral fractures, which resulted in an overall 64% decrease in the number of missed cases related to these injuries. CONCLUSIONS The systematic evaluation of resident discrepancies using a simple software application provides a competency-based metric to assess call performance, establish benchmarks, and develop missed case conferences. This process is expected to result in further reduction in resident discrepancy rates and missed cases.

An Automated Results Notification System for PACS

The purpose of this study was to determine if the interval between an examination being ordered by an Emergency Department physician and his or her review of the report and images could be shortened by notifying the physician that the results were available. This hypothesis was based on work done previously in the Medical Intensive Care Unit that showed that physicians would wait to review results for a time considerably longer than the time required for the radiologist to review the images and provide a preliminary report. The software developments operate properly and show that even simple integration of multiple information systems (PACS, RIS, speech recognition) can provide useful features. Early results indicate that the Emergency Department (ED) physicians prefer the notification system over the previous (travel to check on images and reports) methods. The hypothesized time reductions did occur, although it is not clear that the notification system accounted for all of them. A system for automated notification of radiology results availability has been shown to be possible and practical. To do this automated interaction of 3 systems with a low-level or no electronic integration was required. Although not fully successful for this study, early physician response has been positive, and requests to expand this service hospitalwide now are common.

Experience with radiology workflow and PACS: effects on technologist and radiologist task times

To evaluate the changes in workflow, in the radiology department, after switching from a film-based image management system to a picture archival and communication system.

What do we need to advance PACS workstations: a critical review with suggestions

The technology for building workstations suitable for the display of most medical images has existed for almost a decade. Yet the diagnostic interpretation process has not shifted form film to such workstations in early as large numbers as had been predicted. While, in a large part, this is due to the high costs for acquisition of picture archiving and communications system equipment, there is also the aspect of physician acceptance. Since the workstation serves as the primary system-to-person interface, an examination of the way in which workstations are designed and the way in which radiologists actually work yields some insight into the relative lack of penetration of workstations into the diagnostic image interpretation task.

PACS technologies and reliability: are we making things better or worse?

In the process of installing picture archiving and communications (PACS) and speech recognition equipment, upgrading it, and working with previously stored digital image information, the authors encountered a number of problems. Examination of these difficulties illustrated the complex nature of our existing systems and how difficult it is, in many cases, to predict the behavior of these systems. This was found to be true even for our relatively small number of interconnected systems. The purpose of this paper is to illustrate some of the principles of understanding complex system interaction through examples from our experience. The work for this paper grew out of a number of studies we had carried out on our PACS over several years. The complex nature of our systems was evaluated through comparison of our operations with known examples of systems in other industries. Three scenarios: a network failure, a system software upgrade, and attempting to read media from an old archive showed that the major systems used in the radiology departments of many healthcare facilities (HIS, RIS, PACS, and speed recognition) are likely to interact in complex and often unpredictable ways. These interactions may be very difficult or impossible to predict, so that some plans should be made to overcome the negative aspects of the problems that result. Failures and problems, often unpredictable ones, are a likely side effect of having multiple information handling and processing systems interconnected and interoperating. Planning to avoid, or at least not be so vulnerable, to such difficulties is an important aspect of systems planning.

Prospective comparison of the usage of conventional film and PACS based computed radiography for portable chest x-ray imaging in a medical intensive care unit

The purpose of this study was to compare the efficiency of image delivery, the effectiveness of image information transfer, and the timeliness of clinical actions in a medical intensive care unit (MICU) using either conventional screen-film imaging (SF-HC), computed radiography (CR-HC) or a CR based PACS. When the CR based PACS was in use, images could be viewed in the MICU on digital workstation (CR-WS) or in the radiology department as laser printed hard copy (CR-HC). Data were collected by daily interviews with the house-staff, by monitoring computer log-ons and other time stamped activities, and by observing film viewing times in the radiology department with surveillance cameras. The time at which image information was made available to the MICU physicians was decreased during the CR-PACS period as compared with either the SF-HC periods or the CR-HC periods but the image information was not accessed more quickly by the clinical staff. However, the time required to perform image related clinical actions for pulmonary and pleural problems was decreased when images were viewed on the workstation.

Replacing film with PACS: work shifting and lack of automation

The purpose of this paper is to examine the effects of PACS installation on the tasks related to the performance and interpretation of diagnostic radiological examinations.