Schuylkill Health: RIS Tackles Critical Results, Peer Review, Communications

When Schuylkill Health in Pottsville, Pennsylvania, started evaluating PACS to replace an existing system, a radiology information system (RIS) was not on the shopping list. The radiology department that served two hospitals and two specialty imaging centers used a hospital information system that had provided basic RIS functionality.

Once the PACS replacement evaluation team learned how versatile RIS could be, they began to reconsider. The functionality of a critical-and-urgent-results module offered with a Synapse RIS from FUJIFILM Medical Systems U.S.A., Inc., Stamford, Conn. was a compelling factor that convinced the radiology department and hospital administrators to allocate the funds to purchase an integrated Synapse RIS/PACS. With the launch of the new system in August 2013, visible improvements in workflow and efficiency in the radiology department have had a ripple effect that has spread throughout the hospital, positively impacting patients and caregivers.

Schuylkill Health serves the population of Schuylkill County located in Northeastern Pennsylvania. Its two hospital campuses total 305 beds and several freestanding clinics provide auxiliary services. Four full-time and two part-time radiologists interpret the 125,000 imaging exams performed annually, augmented by the services of an interventional radiologist and specialty after-hours teleradiology.

“The radiology department was making do with what it had, but our hospital administrators knew that major improvements were needed to guarantee critical and urgent results reporting,” says Luke Rissinger, BS, RT®(MR)(CT), CIIP, PACS administrator, Schuylkill Medical Center–East Norwegian Street. “The process was manual, inefficient, and labor-intensive, and not at all foolproof. We always were worried about accidentally overlooking something and having a patient who needed immediate care fall through the cracks. The critical/urgent results reporting and escalation management module in the Synapse RIS has changed this situation dramatically. It’s like night and day.”

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Prior critical-results workflow

In the pre-RIS era, a radiologist would document whatever action he/she took to notify an ordering physician/physician’s assistant/nurse practitioner as part of the radiology report and in a “notes” field in the PACS. This would include the date and time of a requisite telephone call and a summary of the conversation if one took place. Other details included the time a faxed report was sent or a voicemail or answering service message was sent, as well as the need (if applicable) to call again.

However, the only way to track an “open” critical or urgent results notification alert was by manually recording the name of the patient. And although radiology department staff were diligent about adding notes to the patient’s records in PACS after the results had been reported to the ordering physician or the staff covering for him, there was no way to automatically check that this had been done except by opening up the patient’s file using a manual list and double-checking. This was done as part of the department’s protocol, but it was laborious and time consuming.

Today, when a radiologist needs to notify medical staff about critical or urgent results, he or she still picks up the telephone. That is the protocol. But thanks to a streamlined workflow utilizing the Powerjacket of the Synapse PACS, the radiologist is enabled to more efficiently document the process, with every activity made time stamped. If the results are successfully conveyed, a response is noted and the feedback loop is closed.

If it is not, the patient’s file enters one of two “uncompleted” worklists, one for critical results, which must be communicated to an ordering physician or colleague covering him or another for urgent results. A member of the supervisory staff in the department takes responsibility at that point. Hospital policy requires that critical results—such as a cerebral hemorrhage/hematoma, pneumothorax, acute appendicitis, pulmonary embolism, ruptured aneurysm—must be directly conveyed by the radiologist to the patient’s caregiver within 60 minutes. Urgent results, which include such conditions as pneumonia, an abscess, fractures, cholecystitis or congestive heart failure, need to be communicated within eight hours, but can be conveyed to the caregiver by a radiology staff member and then documented in the RIS as an urgent finding.

Joint Commission accolades

The two worklists have brought efficiency and safety to the process, providing the information needed to facilitate escalation and removing patients from the worklist automatically when communication has been made. The staff is no longer burdened about accidentally missing a time deadline. And everything is automatically documented and time stamped. Reports can also be generated for management review.

There was another “bonus” of sorts at the time of Joint Commission review. A CT technologist was asked about the critical-results reporting process. Her complete answer and demonstration of the process brought a verbal accolade for the radiology department.

A similar type of worklist—an emergency department discrepancy worklist—has also made a world of difference with respect to emergency department patients who have x-ray or ultrasound exams after regular workday hours and on weekends. Emergency department physicians provide a preliminary interpretation, which is noted on the PACS, with radiologists reporting the exams the next business day. As with critical/urgent results, there was no way to track discrepancies except manually.

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“Now a worklist exists for discrepancies which is easy for the emergency department to check at regular intervals,” says PACS administrator Mark Dower, BS, RT®(CT), PACS administrator, Schuylkill Medical Center–South Jackson Street.  “This functionality has helped us immensely. When an emergency physician clicks a name on the worklist, the reason for the discrepancy is displayed, along with a link to the radiologist’s report. The physician at this point can close the loop, and if that physician wants to see the image, another command launches display of the x-ray exam in questions. Never does that physician have to log into another application.”

The RIS also is intelligent with respect to follow-up exams. It will automatically generate letters to patients as well as notification worklists. This feature is being used by the women’s imaging center for mammography exam notification. And it tracks patients with positive mammograms and those who fail to return for follow-up procedures.

Ancillary benefits

In addition to documenting and tracking critical and urgent results, the RIS has brought order to a number of other departmental activities, including peer review. The department has elected to make study selection for review a manual activity, but the RIS efficiently keeps track of the process. From management’s perspective, this is an added plus.

The multitude of reports that the Synapse RIS can rapidly and automatically create has impressed the department management. Rissinger and Dower say that the ability to track exam volumes—by imaging suite room as well as by facility—has enabled the department to better optimize use, and to be able to justify the need for additional radiologic technologists when specific facilities are at peak utilization.

Rissinger explains: “This RIS gives us a much more robust way of understanding and responding to what needs to be done because it is so radiology-centric. We are still identifying ways it can help us. But giving you just one example, it has reduced confusion that sometimes occurred when the medical records department requested a CD of patient images. Sometimes multiple phone conversations between departments took place to ensure all requests were completed. The request can now be made electronically with a unique task list—instead of by telephone—and the entire process is automatically recorded and date/time stamped. And—no request gets accidentally overlooked. We also use a special task designation when studies are requested to be viewed with its radiology cloud viewer.”

The physician portal within the RIS has generated a lot of praise by referring physicians. It enables them to order exams for outpatients and notify them when radiology schedulers have made the appointments. The RIS also keeps these doctors informed about completed studies, if a report is ready for review, and if a patient has rescheduled or failed to arrive for an exam.

Rissinger concludes: “The 100% failsafe way of managing critical and urgent results in such an efficient manner convinced us that we needed to invest in the Synapse RIS. But we never realized what a huge impact it would have on everyone in the department. One year later, we can’t imagine how we could work without it.”