RIS-driven Workflow: Enhanced Clinical History Through the EMR
John StrainAccess to clinical history is of utmost importance to the radiologists of The Children’s Hospital in Denver, Colorado. Because the hospital’s main campus and five satellite sites generate around 130,000 pediatric images a year, it’s critical for radiologists to be able to access a patient’s indications and background quickly, while maintaining the pace of their workflow. John Strain, MD, chair of the department of radiology at The Children’s Hospital, says, “We’ve been very aggressive in requiring an indication for a study before we do an exam, but even when you do that, there are times when you’d like to know more. Being one click from a patient chart really is handy, especially with a more complex image.” To support a workflow wherein its radiologists would have easy, one-click access to electronic patient charts, The Children’s Hospital underwent some fancy configuration footwork. Today, its radiologists read from worklists produced by the Synapse RIS (FUJIFILM Medical Systems USA, Stamford, Connecticut) in an electronic medical record (EMR) from Epic Systems (Verona, Wisconsin); they dictate and self-edit reports using systems from Nuance Communications (Burlington, Massachusetts); and they send reports to both the Synapse PACS and the EMR, so that the report within PACS is linked to the full case in the Epic EMR. Tailored Workflow Strain explains that this arrangement dates back to the hospital’s legacy PACS, which (although also integrated with Epic) lacked the capability to access charts rapidly from the EMR. When The Children’s Hospital replaced the legacy PACS with the Fujifilm Synapse platform, it made sense for the radiologists to continue reading through Epic’s worklists. “There was no training required of them,” Strain says. “We basically had no downtime turnover in switching from one PACS to another.” The Epic EMR uses the Synapse RIS to generate the two kinds of worklists that The Children’s Hospital radiologists require, depending on whether they’re reading for the hospital or for the pediatric group with which they contract: subspecialty based and modality based, respectively. “Epic is set up so that when you’re reading in batch mode, prioritized cases are automatically the next to appear in your worklist,” Strain notes. By sorting the radiologists’ work in this way, The Children’s Hospital has been able to attain a turnaround time of less than 2.5 hours for 95% of cases done between 7 am and 10 pm, and a turnaround time of less than 45 minutes for 95% of emergency-department cases. Turnaround time is further decreased by Epic’s ability to preload the next study from the Synapse PACS, even as a radiologist is dictating the last study’s report in Nuance. Managing workflow in this way not only makes access to a patient’s clinical history possible as it reduces turnaround time; it also enables easy consultation with referring clinicians, around 1,500 of whom access The Children’s Hospital’s PACS through secure Web access on a regular basis. “If you’re in the middle of reading a case—and someone comes in and asks you to look at another case—because we read in Epic, we can go into Synapse and pull up the referrer’s case and review it, then go back to the reading mode where we were before,” Strain says. “It’s the best of both worlds.” In addition to providing radiologists with a patient’s clinical history, the Epic–Synapse integration works the other way, enabling the hospital’s referring clinicians to see imaging history—a critical component of lowering cumulative dose. “Today, our physicians can see imaging within the Epic chart, and when they click on it, they can get the report (and are one click from launching the image from PACS),” Strain says. “They don’t have to go in and out of PACS—they can access the images they need straight from Epic, where they’re already working.” Iris Case File The integration has also paved the way for the development of a management system for case files that the team at The Children’s Hospital has dubbed Iris. Strain explains, “A lot of people look at a case file as a teaching file. We look at it differently. We see it as a resource for images that have been taken on patients that we have seen here, or within this network of care. The Iris case file gives us specific examples of cases with similar imaging where we know the specific diagnosis or outcome.” Integrating data from The Children’s Hospital EMR, PACS, and voice-recognition platforms, Iris enables users to filter cases by modality, by age, by diagnosis, or using a word search of the impression or the body of the report. “We can filter through any of those and define cases that might be similar, and once we find those cases, there will be thumbnails entered with them, so we can quickly look at a number of cases,” Strain says. “There’s also a direct link from that case file back into Synapse, so we can pull up the full case by accession number.” Adding a case is easy: A radiologist only needs to drag and drop specific images on the Iris file and enter a diagnosis, after which all other patient and study information fields will be populated automatically. “A month ago, we crossed the 10,000-case mark,” Strain says. “We now have a body of 10,000 cases we can search by multiple means and that are linked back to the medical record of those patients, so you can understand what happened and why they received the diagnoses they did.” The Iris case file provides another useful tool for The Children’s Hospital’s radiologists, augmenting their already enriched understanding of a patient’s radiological and clinical history by providing a library of similar studies to enhance diagnostic confidence. “The case-file enhancement is tremendous for allowing us to look at prior material,” Strain says. “A critical part of the practice is learning from what you’ve done before; to have that information readily accessible and available is a huge advantage.” Cat Vasko is associate editor of Radinformatics.com.