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Practical guide: Medical Imaging ConceptsSteven Horii, MD, FACR, FSIIM

Professor of Radiology, Clinical Director , Medical Informatics GroupModality Chief, UltrasoundHospital of the University of PennsylvaniaAttending Radiologist, Childrens Hospital of PhiladelphiaClinical and workflow

DisclosuresMy wife is a full-time employee of Cerner CorporationSite PI, Phase III clinical trial, ultrasound contrast for liver masses, Bracco Pharmaceuticals, Inc.Expert witness, Blakely Sokoloff Taylor & Zafman, LLP (Patent litigation)IntroductionA tiny bit about clinical stuffThe unavoidability of workflowThe complexity of workflow and multiplication of that through interacting (or colliding) workflowsThe changing healthcare modelWhat that means for youClinicalWhat we doWhat do you mean we, kemosabe?OK, then what do physicians in general do; with some radiology particularsWorkflowHow we do itIn twenty minutes?OK, then Why workflow can seem simpleWhy it generally is notWhy is workflow important?Clinical: An overviewPhysicians:Given a story or complaint by a patient,Try to figure out what, if anything, is wrongFigure out a treatment planTreat the patientIf the patient is not improving, return to bullet item 2Oh yeah, get paidClinical: An overview

Notice anything?From a description of what we do, a flow diagram (of sorts) comes outIt is difficult to separate what we do from how we do itWhat do radiologists do?Image humans (and animals) to:Diagnose diseases or anomaliesGuide and perform proceduresHelp develop treatment plansEvaluate progression or regression of disease (response to treatment)Assist in forensic investigationsImagingMechanical energy (ultrasound)Electromagnetic energyRF (MR imaging)Infrared (thermal)Visible light (endoscopy, ophthalmology, dermatology)Ultraviolet (fluorescence microscopy)Gamma (radiographic imaging)Protons (radiation therapy)Adult liver

A 50 year old man with cirrhosis and worsening LFTsAdult liver: good news for this patient

This is color flow and power Doppler: it shows that the bloodvessels in the liver are not distorted by any mass.Obstetrical ultrasound

How we do it: WorkflowI recommend review of the IHE Profiles for radiology if you are not already familiar with themThe profiles were developed largely through detailed examination of radiology workflow

Scheduled Workflow Profile

Registration

Orders Placed

Orders Filled

Film

FilmFolder

Image Manager& Archive

FilmLightboxreportReportRepository

DiagnosticWorkstation

Modalityacquisitionin-progressacquisitioncompletedacquisitioncompletedimagesprinted

AcquisitionModality15Specifies transactions that function to maintain the integrity of patient, image, and order information across systemsIntegrates modalities with information and imaging systemsBiggest Value of IHESmooth flow of patient, image and order information across systemsStatus updates of ordersIntegrates modalities with information and imaging systems

Why are healthcare workflows so complex?Legacy procedures and systemsWe are idiosyncratic (Paul Chang)Interactions between departmentsMany personnel, each with particular tasks to perform and information neededComplex workflow: intraoperative ultrasoundWe provide ultrasound in the operating room to assist the surgeons in locating structures and planning surgical approachesAbout 20% of the time, the ultrasound changes the surgical planDisplay during intraoperative scanning

With permisson: Susan Rowling, MD, Frank Spitz, MDDisplay: the radiologists view

Intraoperative ultrasound example

A 41 year-old woman with colon carcinoma for resection ofa solitary liver massThe mass looks more like normal liver after compression

This is NOT another metastasis it is an hemangioma;a benign liver lesion.Intraoperative ultrasoundOften resulted in delays for both surgery and radiologySurgeons had to wait for 20 minutes or more for us to arrive with our equipmentFor radiology, it added to patient waiting time (took a radiologist and sonographer out of the Department)Basic workflow: Intraoperative liver

DelaysWe noted that some intraoperative ultrasound studies were subject to much greater delays than othersWe thought that one difference was whether or not the study was scheduled in advanceWe looked at the difference in workflowThe non-scheduled workflow addition

The non-scheduled workflow additionIncluded more stepsEach step involved timeOnce we showed how many more steps were involved, we discussed this with the surgeons and explained that scheduling ahead of time would result in shorter delaysThey now routinely schedule their studiesIntraoperative ultrasoundIllustrates that an already complex workflow in radiology,Is made more complex when it involves interaction with another departments workflowNote that this does not even include the workflow steps done by surgeryIntraoperative ultrasoundAlso shows the need for standardization in the OR (hence the DICOM in Surgery WG)There are vendor-based standards, but they are usually proprietaryThere are standards (HDMI for video) that permit display on different devices, but not integration/interoperationWhy is this stuff important for you?Much of radiology workflow grew out of the film, paper, and pencil ageThis includes not only processes, but organizationRadiology had been largely radiology-centricThis in a time when patient centered has become a goalOpportunitiesOur workflow tends to be supported by thick client, customized softwareIt is neither agile nor adaptableThe rapid changes in healthcare have meant much more difficult transitions for our legacy information systemsBig changes are comingRemember the bit about getting paid?Much of our (meaning healthcare in general) workflow is based on a fee for service modelThe service-oriented specialties (radiology and pathology in particular) are effectively piece workersThe approach to reducing healthcare costsThe US Government has, in response to escalating healthcare costs, attempted to fix this by reducing payments to hospitals and physiciansWhat is the logical response to reduced reimbursement per procedure?Why, perform more procedures, of course!The newer model for reimbursementAccountable careReimbursement is based on outcomes, cost reductions, and appropriateness rather than just what was doneHow can radiology prepare for this?It is why you are (or should be) hearing about quality measures, appropriateness criteria, and meaningful use ExamplesCPOE show that use improves appropriate requesting of imaging studiesACR Imaging 3.0The Leapfrog Group - founded by large purchasers of healthcare services, mostly large corporationsImportance for you (us)We need to be agile and adaptable enough to provide the informatics and information technology resources to support changes in the way healthcare is practiced and reimbursedThe emphasisThe emphasis will be (and is) on:Rapid data miningIncreased patient involvementImproved communication between healthcare providersDemonstrating improvements in outcomeProving increased efficiencyThink about how these things can be accomplishedDo you want to continue to write monolithic thick client applications with numerous customizations?And then have to debug, support, and update them?This meeting gives me hope that there is a better way and you folks are practicing it