A Clearer View: Enriching Radiologist Workflow

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Eliot Siegel, MDWoojin Kim, MDThe next frontier in radiologist workflow won’t be another enhancement to hanging protocols, a faster processor, or an improved graphical user interface, Eliot Siegel, MD, and Woojin Kim, MD, predict. Instead, these two experts in radiology informatics are looking outside the PACS and its workstations to offer radiologists a clearer view of patients’ enriched clinical histories. Siegel, who is professor of diagnostic radiology and associate vice chair for informatics at the University of Maryland Medical Center (UMMC) in Baltimore, says, “We believe PACS will be significantly different in the near future from what it was in the first 20 years. We want a PACS where the workflow for the radiologist is much more tightly integrated with information from the electronic medical record (EMR).” Kim, who is assistant professor of radiology and associate director of imaging informatics at the Hospital of the University of Pennsylvania in Philadelphia, points out that as the radiologist’s role has evolved, the amount of clinical feedback that he or she receives has decreased. “A lot of radiologists will look at an image and say it’s a carcinoma and needs a biopsy, but a lot of times they’d love to find out if it was a malignant tumor, in the end, and they never get that feedback,” he says. Siegel adds that in the analog days, a radiologist might receive some kind of informal clinical information from a referring physician—information that is absent in today’s electronic workflow. “We’re interpreting studies in a vacuum,” he says, “so the question becomes, ‘How can we, in a context-specific way, give the radiologist what he or she needs?’” Deeper Needs For years, radiologists have noted their growing lack of interaction with clinicians—and one casualty of radiologists’ mounting isolation is their understanding of patients’ clinical histories. Of course, this information is increasingly housed in facilities’ EMRs, but as Kim points out, “It takes a lot of discipline to go into the EMR to get that clinical information.” It is amazing, Siegel adds, that “there really isn’t something to provide me with relevant clinical information while being integrated into my workflow in the PACS.” Radiologists aren’t the only ones seeking more from their information systems. Kim notes that the product created by radiology is, of course, the report, and the accuracy and usefulness of that report will be increasingly important to health-care administrators seeking to augment quality while controlling costs. “The ability to mine data is very important—not just for radiologists, but also for administrators,” he says, “but once you’re doing that, you can expend to include other specialties, such as pathology, cardiology, and gastroenterology. You can give a cross-section between radiology and pathology to see which patients live in both worlds in your institution, and then see how many radiology reports were concordant or discordant with the pathology reports. If there are outliers, you can educate them.” The potential of such access to other information systems in the enterprise, which Kim and colleagues have modeled, is high; he says, “It helps refine clinical decision support, improves quality, and reduces overall medical imaging costs.” Siegel adds that this kind of technology will not only provide additional clinical insight, but will also enhance radiologist productivity. “The next realm will be taking information from all those different systems—including dashboarding for business analytics, departmental management, and performance—and putting them together,” he says. “It won’t slow down radiologists, if we do it in an intelligent way. You can show a lot of complex information graphically in a way that can be very rapidly appreciated.” Looking Ahead Kim observes, however, that leveraging enriched clinical histories in radiology will require the intelligence to preselect information that will be useful to the diagnostic process. “You might be impressed with the amount of information you can access, but you can’t look through it all and maintain productivity,” he notes. “The next question is how you know what’s important. Depending on the condition, some results are more important than others, and you have to build in intelligence to rank that for you. Otherwise, you’ll be faced with information overload.” For this reason, Siegel envisions radiologists in the future working with an automated fellow—a computer program that presents a complete view of patients’ clinical histories to give radiologists more information from which to make their diagnoses. Siegel cites the Amalga for PACS radiology product from Microsoft® Corp (Redmond, Washington) as an emerging technology that unlocks the potential for radiologists to leverage information from disparate systems in this automated fashion. “We’re looking at partnering with the PACS vendor and Microsoft so the vendor could use a system like Amalga to bring up the relevant patient information we want to know,” he says. The Amalga for PACS product presents contextual clinical information in template form to drive efficiency and consistency, and enables easy access of prior radiology reports, even those from ambulatory or disconnected RIS environments. “As an academic, I have radiology residents and fellows who find prior studies for me, look in the EMR, and present the patient to me like a clinical case presentation,” he says, “but not everyone has that luxury in real practice. Wouldn’t it be amazing to have a system that could be an intelligent fellow and that, as time went on, would know my workflow and the kinds of questions I’m going to ask?” Kim anticipates a world in which radiologists, given unparalleled access to both their own data and correlated data from throughout the enterprise, are able to improve workflow in myriad ways. “The radiology report has a lot of metadata associated with it,” he says. “You can use that to create a dashboard that’s unique to operational support—to improve quality, to determine degrees of uncertainty, and even to locate laterality errors. When you give radiologists the ability to search their own data, the projects they come up with are fantastic; it opens a lot of doors for creativity.” Kim and Siegel agree that we are on the cusp of an era of unprecedented evolution in radiologist workflow, enabled by a clearer view of patients’ enriched clinical histories. Siegel recalls, “One of the questions we asked in 1991, when UMMC got its first PACS, was, ‘What will we need in 10 or 15 years?’ Today, we are asking that same question. I don’t believe all the concerns about PACS becoming an unchanging commodity. I think we will see a lot of innovation in the next few years, and we’re excited about reinventing what PACS represents.” Cat Vasko is editor of ImagingBiz.com and associate editor of Radiology Business Journal.