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journa l h o mepage: www.i jmi journa l .com

Redefining the sonography workflow through theapplication of a departmental computerized workflowmanagement system

Ming-Feng Lia, Jerry CH Tsaia, Wei-Juhn Chena, Huey-Shyan Linc, Huay-Ben Pana,b,Tsung-Lung Yanga,b,∗

a Department of Radiology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROCb School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROCc School of Nursing, Fooyin University, Kaohsiung, Taiwan, ROC

a r t i c l e i n f o

Article history:

Received 12 August 2011

Received in revised form 4 June 2012

Accepted 4 June 2012

Keywords:

Workflow management system

Quality improvement

Information infrastructure

Patient satisfaction

Radiology

a b s t r a c t

Purpose: The purpose of this study is to demonstrate and evaluate the effective application

of a computerized workflow management system (WMS) into sonography workflow in order

to reduce patient exam waiting time, number of waiting patients, sonographer stress level,

and to improve patient satisfaction.

Methods: A computerized WMS was built with seamless integration of an automated patient

sorting algorithm, a real-time monitoring system, exam schedules fine-tuning, a tele-

imaging support system, and a digital signage broadcasting system of patient education

programs. The computerized WMS was designed to facilitate problem-solving through con-

tinuous customization and flexible adjustment capability. Its effects on operations, staff

stress, and patient satisfaction were studied.

Results: After implementation of the computerized WMS, there is a significant decrease

in patient exam waiting time and sonographer stress level, significant increase in patient

satisfaction regarding exam waiting time and the number of examined patients, and marked

decrease in the number of waiting patients at different time points in a day.

Conclusion: Through multidisciplinary teamwork, the computerized WMS provides a simple

and effective approach that can overcome jammed exams associated problems, increase

patient satisfaction level, and decrease staff workload stress under limited resources, even-

tually creating a win–win situation for both the patients and radiology personnel.

shrinking budgets, increasing cost pressure, manpower short-

1. Introduction

1.1. Background

Radiology, which plays a more important role in today’s ever-changing medical era, has experienced the explosive growth

∗ Corresponding author at: Department of Radiology, Kaohsiung VeteranROC. Tel.: +886 7 3422121x6256; fax: +886 7 3468301.

E-mail address: tlyang.dicom@gmail.com (T.-L. Yang).1386-5056/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reshttp://dx.doi.org/10.1016/j.ijmedinf.2012.06.001

© 2012 Elsevier Ireland Ltd. All rights reserved.

in volume and variety of available services during the past2 decades [1,2]. In order to solve the challenging issues of

s General Hospital, 386 Ta-Chung 1st Rd., Kaohsiung City, Taiwan,

age, and growing demands to increase both the efficiencyand quality of services under resource-limited health facilities[3–5], a simple and effective method is needed [6]. Workflow

erved.

i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 2 ( 2 0 1 3 ) 168–176 169

Table 1 – Service volume and number of sonographersfrom 2007 to 2009.

Year Sonography service volume(exams performed)

Number ofsonographers

2007 45,732 5

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Patients bring the exam orders to theradiology department

Patient wait outside the exam rooms

Outpatient Clinic

Clinicians order sonography

exams

Radiology Department

Front Desk

Crude manual time

scheduling of sonography

exams on the morning or

afternoon at a future date

Radiology Department

Front Desk

Patients arrive according to

the prior scheduling (before10am or 3pm) to register

and obtain a waiting number

Sonography Exam Area

Manual distribution ofsonography exams amongthe sonographers by patient

characteristics

Sonography Exam Room

Patients receive sonography

exam

Exam Day

Pre-visit

Administration

Fig. 1 – Manual workflow before the computerizedworkflow management system.

2008 49,100 52009 50,133 5

e-engineering, that can lead to process streamlining and sim-lification, is inevitably a solution [7].

A radiology department is responsible for routine exam-nations that are frequently performed with high volume,nd approximately 80% of these exams are highly structured,hich are suitable targets to apply workflow managementrinciples [8]. To keep a radiology department runningmoothly and efficiently, a department must keep informationowing between working nodes and use information technol-gy as a tool to implement checks, defaults, and automation toarvest potential benefit of simplification and standardization

6,9]. Therefore, introducing IT into the radiology departmen-al workflow management becomes the appropriate solutionince it can target toward workflow deficiencies and enhanceepartmental operation in different aspects to improve qual-

ty and reduce errors [10]. IT integrated workflow managementpproach allows for dynamic adaptation to react quickly tohe ever-changing needs in today’s radiology ecosystem. Examrocess automation improves the efficiency and effectivenessf radiology services with reduced costs and faster responseimes from staff, especially faster report delivery to affect

edical judgments in time. Such real-time radiology can ben-fit the patients by avoiding unnecessary waiting time fromhe hindrance between intramural or interdisciplinary com-

unication. With free and accurate exchange of informationvailable through IT means, various data and parameters canlso be collected to evaluate departmental performance anddentify potential defective design for further improvement6,8,10–12].

.2. Local problem

ur radiology department provides more than 45,000 sonog-aphy exams per year, and the sonography service volumead been increasing without the corresponding increase in

he number of sonographer over the past few years (Table 1).n addition, sonography had the lowest patient satisfactionue to lengthy exam waiting time according to the annualnonymous questionnaire surveys conducted in our radiol-gy department over the last 3 years. In order to improve theuality of service, previous workflow (Fig. 1) was scrutinized,nd the following three workflow defects were identified:

. The previous manual workflow (Fig. 1), including thesequence of initial service registration at the front desk,time scheduling, and exam room assignment, was tediousand time-consuming [13]. It was solely dependent on the

experience of individual staff member, causing the processto be unreliable and prone to human errors. For instance,breast sonography may be assigned erroneously to male

sonographers, or critical patients could not receive promptexams as needed.

2. Much more patients were waiting than needed due to acrude manual exam scheduling, i.e., asking all patients toreport to the front desk at two fixed time points in a day(10 am and 3 pm) and wait until the exam. The patientshad to wait longer, and the sonographers were stressedout from the numerous patients waiting outside the examrooms or interrupting the ongoing exams. Quarrels anddisputes between our staff and patients often ensued.

3. There was no means to monitor the execution status ofeach exam room so that immediate problem detection was

not possible.

170 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 2 ( 2 0 1 3 ) 168–176

Outpatient Clinic

ClInicians order sonography

exams with accurate

scheduling via hospitalinformation system

Radiology department front

desk

Patients register and obtaina waiting number while

being assigned to an exam

room automatically

Exam

Schedule

Fine-Tuning

Automated

Patient

Sorting

Algorithm

Sonographers

perform examsPatients receive

exam

Sonography Exam Room

Digital

Signage

Broadcasting

Anywhere with Internet

access

Radiologist

Teleimaging

Support

System

Status outside the

exam room

Exam waiting

time

approximation

Problem detection

Real-time

Monitoring

System Patients wait outside the exam rooms

Exam Day

Pre-visit

Administration

Fig. 2 – Workflow after the computerized workflow management system.

Thus, in order to solve all these problems as a wholewith improved efficiency and equal quality of sonographyservices, applying IT solutions into workflow managementsystem (WMS) became the mandate and logical strategy forthis difficult situation.

The purpose of this study is to demonstrate and evaluate

the effective application of a computerized WMS into sonog-raphy workflow in order to reduce patient exam waiting time,number of waiting patients, sonographer stress level, and toimprove patient satisfaction.

2. Materials and methods

2.1. Development environment

The development environment is a radiology department

with 29 full-time-equivalent radiologists and 5 sonogra-phers performing more than 45,000 sonography examsannually in a tertiary care public hospital with 1413beds.

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.2. Infrastructure of the computerized WMS

e built a computerized WMS (Fig. 2) to transform the manualorkflow since October 2009 with a collaborative team com-osed of radiologists, IT specialists, and radiographers. Theationale to redesign our workflow management system waso target and overcome the three deficiencies from our pre-ious manual workflow with IT integration. The new WMSonsisted of an automated patient sorting algorithm, a digitalignage broadcasting system of patient education programs,

real-time monitoring system, exam schedules fine-tuning,nd a tele-imaging support system.

The automated patient sorting algorithm, the digital sig-age broadcasting system, and the real-time monitoringystem were developed in Microsoft.net 3.5 framework usingisual studio 2008 as integrated desktop environment to yieldll necessary ASP code-based webpages. To avoid furtherorkload on the database farm of our existing radiology infor-ation system (RIS)–PACS web-based platform, Microsoft SQL

008 was chosen for a repository of the new WMS to operates a paralleling yet stand-alone system. The exam schedulene-tuning was designed under our hospital’s mainframe-ased hospital information system, which was an interactiveomputer system from IBM’s Patient Care System. The tele-maging support system used commercialized broadcastingnd recording devices from DistanceDoc (Mediphan, Canada)ith webpage access capability. For users, except for the exam

chedule fine-tuning, the computerized WMS ran within theindow frame of the web browser and on the same webpage

hat displayed RIS information.

.2.1 Automated patient sorting algorithmn automated patient sorting algorithm (Fig. 3) was devised tossign waiting patients to the proper sonography exam roomased on the exam priority, exam type, and gender. Under thislgorithm, critical patients were automatically identified andanked highest in priority, who would then receive the exami-ation as soon as possible, while other waiting patients of thatxam room would be notified of this emergent exam from theigital signage system. Then, patients scheduled for a gen-er specific exam would be assigned to the appropriate examoom. Finally, the remaining patients were evenly distributedmong the available sonographers.

.2.2 Digital signage broadcasting system of patientducation programsigital signage broadcasting system enhanced patient educa-

ion through video programs played via electronic displays.he video programs were customized individually among theifferent exam rooms according to the ongoing exam typesnd provided all the need-to-knows to the viewers, especiallyafety-related. The patients could enjoy the education pro-rams tailored for each specific exam while waiting. If thereas a critical patient requiring immediate examination, newsash messages would be displayed, acting as an adjunctiveole of the automated patient sorting algorithm.

.2.3 Real-time monitoring systemhis monitoring system (Fig. 4) provided the real-time statusf each exam room via a floor plan demonstration, including

f o r m a t i c s 8 2 ( 2 0 1 3 ) 168–176 171

the who (number of waiting patients and current patient num-ber), when (exam waiting time represented by three differentcolors: green indicating a waiting time of less than 20 min,yellow indicating a waiting time of 20–30 min, and red indi-cating a waiting time of more than 30 min), where (examroom number), and what (type of exam). This information wasavailable to everyone. Our staff could access detailed exampatients information instantly from a webpage through hyper-links (Fig. 4) while the patients could see basic exam roomstatus via the digital signage system. Such system enabledour staff to be able to detect and hence solve any probleminstantly.

2.2.4 Exam schedule fine-tuningThe sonography exam scheduling of our department prior toOctober 2009 was done manually with patients being sched-uled in a crude fashion, i.e., asking all patients report to thefront desk at two fixed time points in a day (10 am and 3 pm),which resulted in a longer exam waiting time. To resolve thisissue, monthly intramural meetings were held to discuss overfine-tuning sonography exam schedules by analyzing the datafrom the month before. After several months of discussion andanalysis, a 15-min interval time slot per exam turned out to bethe reasonable length of time to allocate each exam appoint-ment, thereby spreading out the exams evenly throughoutthe working hours and preventing potential jamming situ-ations. Furthermore, the fine-tuned scheduling system wasintegrated into the hospital information system, so that theclinical doctors could make exam appointments more patient-friendly.

2.2.5 Tele-imaging support systemA broadcasting and recording device was installed ontoeach sonography machine, which broadcasted the real-timeconsole images simultaneously onto any computer and beaccessed via a webpage. The radiologists could check on theongoing sonography exams without the need to walk into eachexam room [14]. Solving problems encountered by the sono-graphers were achieved via mouse clicking and consultationphone calls. Through the use of mobile devices with internetaccess, such as smartphones or tablets, the radiologists wereable to perform the same tasks anywhere outside the hospi-tal. This system allows sonographers to quickly confirm on theexam images taken with the radiologists, especially when theradiologists were not readily available.

2.3. Measurement of improvement

Most of the complaints, dissatisfaction, and quarrels betweenthe patients and staff originated from lengthy exams waiting.Therefore, exam waiting time, sonographer stress level, andpatient satisfaction regarding exam waiting were measured.

Exam waiting time, defined as the difference in time betweeninitial front desk registration and the moment a patient iscalled for examination, before and after implementing thecomputerized WMS was calculated from these two times-

tamps of each exam in the database [15].

Sonographer stress level was assessed through a visual ana-logue scale (VAS) before and after deploying the computerizedWMS. This scale consisted of a 10 cm line drawn on a paper

172 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 2 ( 2 0 1 3 ) 168–176

Sonography exam orders

Critical patients Scheduled patients

Male Female

Male specific exam

(TRUS†, testicular,

penile sonography)

Female specific exam

(breast sonography,

age < 60‡)

Gender-neutral exams

The next sonographeravailable

Male sonographerEvenly distributed

among sonographersFemale sonographers

†TRUS: transrectal ultrasound‡Females under 60 years old are assigned to female sonographers to maintain a sexual harassment free workplace environment

Fig. 3 – Automated patient sorting algorithm.

Fig. 4 – Miniature illustration of the real-time monitoring system interface. (For interpretation of the references to color inthis figure legend, the reader is referred to the web version of the article.)

i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 2 ( 2 0 1 3 ) 168–176 173

Table 2 – Patient satisfaction regarding exam waiting time.

Pre-intervention (2009/4, n = 120) Post-intervention (2010/4, n = 120) p valuea

1 (very dissatisfied) 10 (8.3%) 0 (0%)

<0.0012 (dissatisfied) 16 (13.3%) 0 (0%)3 (average satisfied) 32 (26.7%) 17 (14.2%)4 (satisfied) 37 (30.8%) 39 (32.5%)

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5 (very satisfied) 25 (20.8%)

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hat represented the stress levels to measure. The sonogra-her was informed that one end of the line represented thebsence of the stress and the other symbolized the mostntense stress the sonographer could imagine. The sonogra-her scored the intensity of stress level marking the pointetween both ends that more accurately represented thetrength of the stress experienced. The result was quantifiedeasuring the distance from zero to the point marked by the

onographer [16].Patient satisfaction regarding exam waiting was assessed

hrough a 5-point Likert scale [17] ((1) very dissatisfied; (2) dis-atisfied; (3) average satisfied; (4) satisfied; (5) very satisfied)efore and after implementing the computerized WMS, as aubjective indicator of improvement in the patients’ points ofiew [18,19].

We were also interested if the computerized WMS wouldffect the total amount of examined patients before and afterhe intervention, so the number of examined patients per monthas recorded from the database.

.4 Data collection

rom March 2009 to September 2009, the exam waitingime and the number of examined patients receiving sonog-aphy exams in the radiology department were recordedn = 18,939). Stress levels (VAS) of all sonographers (n = 5) werelso assessed every two months. Patient satisfaction regardingxam waiting was collected by distributing anonymous ques-ionnaires (n = 120) over one month (April 2009).

After the computerized WMS was implemented sincearch 2010, the exam waiting time and the number of exam-

ned patients receiving sonography exams were recordedn = 19,656) until September 2010. Stress levels (VAS) of allonographers (n = 5) were assessed every two months. Patientatisfaction regarding exam waiting was collected by distribut-ng anonymous questionnaires (n = 120) randomly over one

onth (April 2010).From October 2009 to February 2010, the computerized

MS was still under construction and field testing, so the datauring this period of time was excluded. No personal iden-ifying information was collected (such as name or address)hroughout the study.

.5 Statistical analysis

ndependent samples t-test was used to analyze the difference

f exam waiting time; Paired samples t-test was used to ana-

yze the difference of sonographer stress level and the numberf examined patients; �2 test was used to analyze the differ-nce of patient satisfaction regarding exam waiting before and

64 (53.3%)

after computerized WMS implementation. Interval variableswere presented as mean ± standard deviation (or 5 and 95 per-centile if data were skewed), while categorical variables weresummarized as frequencies and percentages. A p value lessthan 0.05 was considered to indicate significant differences.The data were analyzed with SPSS software (v.19.0).

3. Results

3.1. Decrease in exam waiting time

The sonography exam waiting time of 18,939 patients duringMarch 2009 to September 2009 (30.50 ± 20.40 min, 5th per-centile = 7.17 min, 95th percentile = 65.22 min) had decreasedsignificantly (t = 54.25; 95% confidence intervals of differ-ence = 9.82–10.55 min; p < 0.001) compared to the waitingtime of 19,656 patients during March 2010 to September2010 (20.30 ± 16.17 min, 5th percentile = 0.88 min, 95th per-centile = 47.90 min).

3.2. Decrease in sonographer stress level

The sonographer stress levels were assessed three timesbefore and after the implementation of the computerizedWMS. However, VAS from one sonographer was not includedinto our statistical analysis due to the retirement of onesonographer and the recruitment of another new staff. Thesonographer stress level evaluated by VAS had decreased sig-nificantly from 7.46 ± 1.00 cm to 2.33 ± 0.68 cm (t = 7.44; 95%confidence intervals of difference = 2.94–7.34; p = 0.005; n = 4)after introducing the computerized WMS.

3.3. Increase in patient satisfaction regarding examwaiting time (Table 2)

Patient satisfaction regarding exam waiting time was sig-nificantly different (Pearson’s �2 = 47.73; p < 0.001) before andafter the use of computerized WMS. The percentage of “sat-isfied” and “very satisfied” patients after the interventionhas increased from 51.6% to 85.8%, indicating an increase inpatient satisfaction.

3.4. Increase in the number of examined patients

The number of examined patients increased significantly

from 2705.57 ± 211.03 persons to 2808.00 ± 227.12 personsper month (t = −6.64; 95% confidence intervals of differ-ence = −140.19 to −64.67; p = 0.001) after introducing thecomputerized WMS.

174 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 2 ( 2 0 1 3 ) 168–176

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10

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3.5. Decrease in the number of waiting patients atdifferent time points in a day

Fig. 5 illustrates the distribution change of sonography examwaiting patients over time from two same weekdays of differ-ent weeks chosen randomly before and after the applicationof computerized WMS. The number of waiting patients at thedifferent time points in a day has markedly decreased.

4. Discussion

Our experience suggests that WMS modification withsystems-level intervention through IT means, such as the onedescribed, is a simple but feasible strategy for quality improve-ment in resource-limited settings. Our computerized WMS isproven to be beneficial from the hospital, medical personnel,and patient points of view. The total number of examinedpatients has increased significantly after the implementationof the computerized WMS. Furthermore, given the challenginglogistics of applying a new WMS onto a pre-existing manualworkflow, the total cost of our new WMS was approximately$80,000 US dollars, including every piece of hardware andsoftware newly installed. In addition, it took only 5 monthsof preparation, installation, field testing, and staff trainingfor our new WMS to be fully operational. From the hospi-tal’s point of view, the overall cost (in time and money) wasrather inexpensive while capable of increasing the total num-ber of examined patients under limited budget and humanresources.

Our computerized WMS not only decreases the exam wait-ing time, but also the number of waiting patients in a day is

also decreased. From the patients’ points of view, the patientsatisfaction regarding exam waiting has increased signifi-cantly because the patients do not need to wait as long andare able to anticipate when the exams will take place from

nography exam waiting patients over time.

the real-time monitoring system [20]. While the patients arewaiting outside the exam room, they will be preoccupied andcan learn from the digital signage education programs, whichmay help to ease the anxiety from the lack of understandingof the medical exam [21].

From the sonographers’ points of view, our computerizedWMS offers several benefits. The interactive interface of ourWMS uses the same web page that displays RIS information,which was easy to adapt to with relative ease in transitionover a short period of time. The automated patient sortingalgorithm saves the time of manually sorting patients intothe suitable exam rooms. The real-time monitoring systemallows the sonographers to understand the waiting status ofthe exam room compared to absolutely ignorant of the condi-tion outside the exam room prior to the computerized WMS.Whenever there is an emergent examination, patient jam, orthe need for second opinion from the radiologists, real-timemonitoring system, and tele-imaging support system promptproblem detection and solving to take place. Fine-tuning examschedule can prevent patient jam situation by evenly dis-tributing patients across the day rather than gathering allthe patients to wait at a certain time. All the aforementionedstrategies contribute to relieve the sonographers stress leveland subsequently maintain the quality of examination [22].The streamlining of workflow through the application of thecomputerized WMS allows the sonographers and patients tobe able to see the bigger picture and be in a better position inthe working dynamics.

Our own PACS team, endeavoring to establish and main-tain the RIS and PACS of our hospital over the last decade[23], is familiar with a radiology departmental workflow, fromorder placing, order filling, imaging acquisition, structuredreporting, to all the intricate logistics behind an enterprise-

wide imaging and reports distribution. Therefore, when wesaw the need to fundamentally change the workflow of ourdepartment, we decided to create an original WMS with our

a l i n f o r m a t i c s 8 2 ( 2 0 1 3 ) 168–176 175

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Summary pointsWhat was already known on the topic?

• Radiology department is responsible for routine exam-inations that are frequently performed with highvolume production, and approximately 80% of theseexaminations are highly structured, which is a suitabletarget to apply workflow management principles.

• Introducing information technology solutions intoradiology workflow management are powerful strate-gies to enhance departmental operation through examprocess automation to improve the efficiency andeffectiveness of radiology services.

What this study added to our knowledge?

• Multidisciplinary teams and strategies are essentialdue to the complexity of healthcare system.

• Patient exam waiting time and sonographer stresslevel can be reduced with computerized workflowmanagement approach.

• The number of examined patients increased after thetransformation from manual workflow to computer-ized WMS.

• Patient satisfaction increase when the patients’ wait-ing time shortens and when they are able to anticipatewhen the exams will take place.

• Understanding the number of waiting patients and thecurrent waiting status of all the patients outside theexam room help to decrease sonographers’ stress level.

i n t e r n a t i o n a l j o u r n a l o f m e d i c

ACS team. The computerized WMS was made possible fromhe collaboration between radiologists, radiographers, and ITpecialists that had worked closely along every step of infra-tructure development. The WMS was tailored to our needsnd was capable of continuous customization and flexibledjustment as we wish whenever a problem was encoun-ered. The web-based design interface was most convenientnd readily available to each member of the team, allow-ng timeless and boundless access to everyone. Numerousnline meetings were held to exchange expertise and to com-unicate ideas, to ensure the smooth interaction betweenembers of the entire team, to review and identify problems,

o expand the scope of our service, and to maintain the properunctioning of the entire system. The computerized WMSltimately enables a way to multidisciplinary teamwork andooperation between staff of different fields and backgroundso reach a common goal – to improve patient satisfaction andhe quality of our service in the current environment of theealthcare complexity [6].

We believe technologies should empower the medical staffo benefit more patients, not to introduce more complexityesulting in further cost in time and money [24]. Our computer-zed WMS, although linear and not most innovative, provides

simple and effective approach toward a realistic problemncountered in everyday radiology departmental operation.he results from our study have proved the clinical signifi-ance of our method in quality improvement. It can be easilyeproduced with relatively low IT and hardware requirementspecially in relatively resource-poor environments. More-ver, this study used a thorough approach to evaluate theegree of quality improvement and effectiveness of the com-uterized WMS from the hospital, medical personnel, andatient points of view.

However, our study has a few limitations. First, the imple-entation of our computerized WMS was carried out at a

ingle organization only and requires further studies to ensureuccessful reproducibility and smooth workflow streamliningn other healthcare institutes. Secondly, more frequent assess-

ents of sonographer stress level assessment through VASs needed to eliminate potential influences from particularatient behavior towards the sonographers because the sono-rapher stress levels were assessed only three times beforend after the intervention. Thirdly, because there was no con-rol group, we could not specifically eliminate the effects ofnmeasured external environmental factors operating region-lly and nationally that might have served as confounders.astly, analysis on the impacts of other outcome could also beonsidered in future researches, including cost-effectivenessnalysis on revenue and expenditure, medical error reductionnalysis, patient relationship improvement analysis, etc.

. Conclusion

e report a computerized WMS with systems-level interven-ion via IT means, which is a simple but feasible strategy

or quality improvement in resource-limited settings throughontinuous multidisciplinary teamwork and cooperation. Theomputerized WMS can overcome jammed exams associatedroblems, increase patient satisfaction level, and decrease

staff workload stress under limited resources, eventually cre-ating a win–win situation for both the patients and radiologypersonnel.

Authors’ contributions

Study concepts was given by Tsung-Lung Yang, Wei-JuhnChen, Ming-Feng Li. Study design was given by Tsung-LungYang, Ming-Feng Li. Data acquisition was done by Wei-JuhnChen. Quality control of data and algorithms was given byWei-Juhn Chen. Data analysis and interpretation was doneby Ming-Feng Li, Jerry Tsai, Huey-Shyan Lin, Huay-Ben Pan.Statistical analysis was done by Ming-Feng Li, Huey-ShyanLin. Manuscript was prepared by Ming-Feng Li, Jerry Tsai.Manuscript was edited by Ming-Feng Li, Jerry Tsai. Manuscriptwas reviewed by Tsung-Lung Yang, Huay-Ben Pan.

Conflict of interest

There are not any potential conflicts of interest includingemployment, consultancies, stock ownership, honoraria, paidexpert testimony, patent applications and registrations byMing-Feng Li et al.

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