Radiologue: Whole-system Communications for Radiology
The San Francisco General Hospital/University of California–San Francisco Department of Radiology has created a groundbreaking communications tool called Radiologue. Alexander V. Rybkin, MD, a radiologist in that department, described the system in “A Web-based Flexible Communication System in Radiology,” which he presented in Minneapolis, Minnesota, on June 5, 2010, at the annual meeting of the Society for Imaging Informatics in Medicine. Radiologue shows great promise not only in improving communications within radiology departments and practices, but in untangling knotted workflows and enhancing patient care. By giving all parties involved in imaging access to user-annotated information on studies and patients in real time, it replaces whiteboards and logbooks, both of which are often illegible or inaccessible. Based on the operations of a typical department, one must assume that Radiologue also does away with a number of exasperating, ineffective, or frantic phone calls. The starting point, Rybkin says, was a busy department’s chaotic communications routine, which employed procedure logbooks and whiteboards. Since San Francisco General Hospital handles 50,000 emergency-department visits, 18,000 admissions, and 25,000 CT exams per year, the potential for poor communications (and poorer consequences) was immense. Although the hospital had addressed many potential problem areas using quality-improvement and workflow-enhancement techniques, bottlenecks could still be created by failed communications in radiology. A Comprehensive System Radiologue was built using Microsoft® ASP.NET, which permits users to construct Web-based applications on an enterprise scale with only minimal programming. Microsoft Ajax controls were used on the client side to make the Web pages respond to users’ input and other actions. Based on a service-oriented architecture, Radiologue uses read-only data from the RIS as its core. Through HTTP, information from the hospital information system (HIS) and PACS is added; these data flow in both directions, unlike the RIS data, and the HIS and PACS can be opened by users as Web windows (with proper validation). The workstations of technologists and department managers also use HTTP for multidirectional communications. Messages can be exchanged by the radiology department’s technologists, physicians (including residents and fellows), and staff, as well as by users outside the department. These include attending/referring physicians, emergency-department physicians, and nurses. Among many other possible actions, physicians can change the order and/or priority of studies (see figure), residents can flag interesting cases, and clinicians can add patient-history notes that will later streamline study interpretation. Radiologue maintains constantly updated lists of patients and procedures, accompanied by integrated data from the RIS, HIS, and PACS, as well as by users’ notes in flexible, configurable formats. A stoplight color-coding system uses red to advise any list’s viewers of critical information at a glance and yellow to indicate the addition of preliminary data of medium importance, with green showing that all is proceeding as expected. This comprehensive integration gives users not only a means of communicating instantly, effectively, and multidirectionally, but a better grasp of how the radiology department as a whole is operating at any time. Rybkin’s department chose to develop Radiologue using Web services, he says, because it needed flexibility. The system can be developed, configured, and changed in many user-friendly ways, he adds, and it allows the creation of notes of many kinds and multiple functions. Many are text boxes, for instance, but others are checkbox questionnaires, and some types of notes can be used to deliver system information to clinicians. Radiologue’s Impact Rybkin points out that in traditional radiology communications, messages tend to move only in one direction and to have only a single function. Radiologue, instead of behaving as this linear model does, works in what he calls a more holistic way, making messages and their functions resemble a web instead of a lone string. In response, Radiologue’s 2,154 enthusiastic users created a communications web of their own during the system’s first 17 month of use. They have generated 54,000 new notes, which have been viewed 59,000 times; the system has been accessed 36,000 times by radiologists and 31,000 times by others. Rybkin reports that the system is now integral to clinical workflow outside radiology, in addition to being an indispensable part of the radiology department’s operations. Improved communications, he says, have led to enhanced service to clinicians, better documentation and quality assurance, and (most important) improved patient care. Because most people in the hospital who have any contact with radiology now use Radiologue, its influence reaches beyond the department—to the ICU, the emergency department, the clinic, the floor, and the bedside. By showing the status of patients and studies in real time, it creates an asynchronous workflow that is far more efficient. When one process stops, it no longer brings the rest of the workflow to a halt; instead, Radiologue allows the system’s fully informed users to anticipate and work around the trouble spot. For example, Rybkin says, an outpatient arriving at the clinic for a CT exam might not be sent to the radiology department for scanning at the expected time if there is an identification failure in the clinic. Before Radiologue was adopted, this could stall the entire system, creating holdups not only in the clinic and in the radiology department, but on nursing floors, in the ICU, and in the emergency department. Under the previous communications system, an ICU nurse, noticing that a particular ICU patient was next in line for CT scanning, would call a respiratory therapist, and the two would accompany the patient to the radiology department—only to be left standing in a hallway, Rybkin says, while the department tried to sort out the clinic patient’s identification problem. Using Radiologue, however, the clinic can add a note stating that there has been an identification failure. If this will cause a delay, the technologist can add a note that then stops the ICU nurse and respiratory therapist from bringing the next patient to the radiology department. All concerned can move on to other tasks instead of wasting time waiting. Expanding Utility Beyond its everyday uses, Radiologue can be helpful in several other current and future areas, and Rybkin reports that the department is developing more applications for the system. By allowing both high-level and detailed views of operations—in much the same way that an interactive map permits the user to zoom to the most relevant level of detail—Radiologue lends itself to many administrative uses. For example, Rybkin says, managerial attention to workflow problems is facilitated because the system tracks how (and especially when) users access the system. The time stamps associated with each access episode create a chronological map that makes areas needing improvement more obvious, and might even suggest what those improvements should be. The system incorporates quality-assurance functions that are based both on the communication logs and on the underlying databases; it also makes creating educational material easy, Rybkin says. Residents, for example, can review their cases for discrepancies noted on final interpretations. Automatic alerts for urgent results can be generated, arrival times for patients or results can be predicted, and the system can be tied to computerized provider order entry. Rybkin predicts that the development of new functions for Radiologue will be an ongoing project. He also notes that incomplete (and entirely missed) communications have been identified by the Joint Commission as one of the primary reasons for the medical mistakes that plague the health-care system today. He modestly states that a system such as Radiologue, by promoting ubiquitous communication and full access to up-to-date information, will naturally address such deficiencies. In developing Radiologue, his department has used straightforward tools—combined with a deep understanding of how a radiology department can and should work within its institution—to make great strides toward improved workflow, higher levels of efficiency, decreased frustration, and better patient care. Kris Kyes is technical editor of Radinformatics.com.