in the age when many radiology departments become computerized , many aspects of a radiologist s workflow rely on word of mouth , pen and paper , telephone , and fax .
radiologists use these ad hoc communication strategies when they deliver important findings , when they interact with support personnel , such as technologists and nurses , or when they help determine the priority of studies to be done .
these communications have limited scope ( they are usually person - to - person ) , they are difficult to document and track ; they distract radiologists from the task of image interpretation , causing workflow delays and reduced productivity .
several reports have outlined attempts to replace informal communication with internet - based systems [ 14 ] .
most of them concentrate on communication of  wet readings  between on - call radiologists and referring healthcare providers .
these systems exemplify the conventional view of radiological communication as a  loop ,  in which information flows in the orderly fashion from the provider to the radiologist ( in the form of a request ) and back to the originator ( in the form of a  wet reading  ) .
however , the reality of the radiology department in a busy hospital does not fit this simplified model .
information about any particular study flows to the on - call radiologist from multiple directions .
multiple members of the emergency or trauma surgery team may contribute crucial pieces of historical information .
wet readings  , directs the workflow by assigning priorities to requested studies , determines protocols , and provides feedback to the staff on the studies quality .
most of these interactions occur informally because they are not anticipated by a system where the roles and the direction information flow are rigidly defined .
in contrast , one can reach virtually anyone by phone , fax , or pager .
the content of a conversation ( either by telephone or face to face ) is not constrained by the underlying technology .
the key advantage of the informal means of communication is their flexibility . in developing our own internet - based communication system , we made flexibility the primary goal of design .
we consequently found the system useful for multiple elements of radiology workflow that had previously been handled informally . the inherent flexibility or our system also allows us to extend it in ways we did not anticipate at the beginning .
our system , codenamed radiologue , consists of a web application running on the hospital intranet . for the convenience of radiologists
, our system can be accessed from the departmental picture archiving and communication system ( pacs ) .
healthcare providers and support personnel access radiologue through the hospital - wide information system and electronic medical record ( siemens lcr / invision ) .
radiologue supports multiple modes of role - aware user authentication to ensure that only authorized users have access to protected health information .
the result of this arrangement is that access to the system is secure and ubiquitous throughout the healthcare enterprise .
radiologue application provides a web portal , which includes a configurable worklist of current radiological studies .
the messages ( or  notes  ) are highly configurable , and can take the form of a  wet read  , study protocol , referring physician s request for specific information , or a comment by the technologist who performs the study .
the ability to configure and extend the messages provides the flexibility to use them in different workflows .
our application has become a tool for collaborative management of radiological cases , which allows multidirectional data exchange .
we believe that such architecture improves upon the standard model of the unidirectional  communication loop  of healthcare information exchange .
blog  or a  wiki  than to a traditional repository of medical information .
the web application resides on a hp proliant 5200 server ( hewlett packard , palo alto , ca ) running windows server 2003 r2 operating system ( microsoft , redmond , wa ) , which includes the internet information services web server software .
this technology has a proven track record in development of enterprise - level web software .
it has rich support for interactions with databases and xml ; it has advanced tools for creation of object - relational mapping , and it emphasizes modern web design techniques , including web services and asynchronous javascript and xml ( ajax ) .
perhaps more importantly , microsoft technology is ubiquitous throughout medical information systems , and has the advantage of familiarity and supportability by most it personnel . using proven technology
the database layer of our application consists of sql server 2005 ( microsoft , redmond , wa ) , which is the preferred database for asp.net technology .
this database software provides a rich and well - documented set of features that ensure logical integrity of the data within the application .
it is tightly integrated with the development environment ( visual studio 2005 ) and provides tools for simplified administration tasks , such as data backup .
it periodically queries the radiology information system ( ris ) via a standard odbc - compliant database connection to retrieve information about the current radiological studies .
the web application displays this information to the end user in the form of a customizable worklist , which is displayed in the web browser ( fig .  2 ) .
the studies on the worklist are initially ordered chronologically , but they can be rearranged by the end user to reflect clinical priority .
such continuous communication between the central application server and client browser is made possible by ajax technology , which is used in the modern blogging and instant messaging systems . 

it is integrated into his / emr and into pacs through html links using vendor - specific web interfaces .
b internal architecture . radiologue is an asp.net application that utilizes sql server as a database engine .
radiologue serves dynamically generated html pages , which are specific to the source of connection ( his / emr vs. pacs vs. browser ) and to the users role ( radiology resident vs. er attending vs. technologist)fig . 
various notes are displayed to the right of the study demographic information as color - coded buttons .
the notes can be immediately accessed by clicking on the buttons schematic representation of the radiologue web application s architecture . a external connections .
it is integrated into his / emr and into pacs through html links using vendor - specific web interfaces .
radiologue serves dynamically generated html pages , which are specific to the source of connection ( his / emr vs. pacs vs. browser ) and to the users role ( radiology resident vs. er attending vs. technologist ) worklist view of the active studies .
various notes are displayed to the right of the study demographic information as color - coded buttons .
the notes can be immediately accessed by clicking on the buttons in addition to reordering the worklist , the users can add information to the studies on the worklist in the form of notes ( fig . 
a  note  is the central feature of the radiologue application , as it is responsible for the system s flexibility .
a note is similar to a  topic  in the context of a blog or a  conversation  in an instant messaging system .
each note of a certain type is permanently associated with a radiological study , and is displayed in the worklist as a color - coded button .
users contribute to notes collaboratively ( however , the application tightly controls who can edit or view each note ) .
although all notes share basic features and are treated by the application in similar ways , they can also be customized to reflect differences in function .
, it accepts changes only from the on - call radiologists , and is displayed to referring healthcare providers while it is hidden from others .
the note s display properties can be set up to reflect the urgency of information it contains .
a  wet reading  containing a critical result can be displayed as a bright - red button on the emergency physician s worklist .
further , a critical wet reading may be configured to page the ordering physician if it is not viewed in a certain time interval . 

,  protocol  ,  nurse note  ,  ed note  , and many others .
for example , tech notes are displayed only to radiologists and technologists , and history notes are displayed to everybody , including referring physicians and nurses .
for example , tech notes are displayed only to radiologists and technologists , and history notes are displayed to everybody , including referring physicians and nurses .
,  medium  , or  critical  by using the radiologue system , one can define arbitrarily many note types and user roles .
it can also grow to encompass additional aspects or radiology workflow as more user and note types are added after initial implementation .
as notes are modified and viewed by the users of the system , all access time - stamped and logged by the application ( fig . 
such logging fulfills health insurance portability and accountability act ( hipaa ) requirements , but , in addition , the resulting database is constantly mined for important operational data which is fed back to the users .
this data are graphically represented in the form of a dashboard , which is available to the users who are configured as managers . 

all actions performed by the users or by the system are logged in the database .
logging information is accessed through a specialized interface that allows searching and sorting on multiple demographic parameters access log page .
all actions performed by the users or by the system are logged in the database .
logging information is accessed through a specialized interface that allows searching and sorting on multiple demographic parameters
table  1 demonstrates the roles and notes we defined at our institution . for the initial implementation of the radiologue system
a purpose - built wet reading system already existed elsewhere in our institution , and the radiologists ( residents and attendings ) were already familiar with the wet reading workflow . on -
call residents and fellows use this system to communicate their impressions to the healthcare providers regarding cts and mris performed at night on weekdays and on weekends .
the residents enter their  wet readings  on a web form accessible directly from their pacs stations .
the form allows the residents to mark the urgency of the note as critical , medium priority , and low priority ( which is the default setting ) .
healthcare providers ( residents and attendings in the emergency department ) access the system directly from the electronic medical record ( emr ) , which displays the worklist of pending studies for their patient .
healthcare providers access  wet readings  by clicking on color - coded buttons next to the study of interest .
table  1the roles defined within radiologue , with their associated note types and permitted actionsrolenotesactionsattending radiologistpreliminary read , review read , history note , protocol note , interesting casechange study priority , qa viewresident radiologistpreliminary read , history note , protocol noteqa viewer attendinghistory note , er notechange study priorityclinical mdhistory note , md notenonenursehistory note , nurse notenonetechnologisthistory note , tech notechange study prioritymanagernoneuser administration , access log , departmental dashboard , critical result report , qa report , new roles , new notesa user in a particular role can create and nondestructively edit the corresponding notes .
actions represent functions , which are not tied to specific notes , such as management and qa functions the roles defined within radiologue , with their associated note types and permitted actions a user in a particular role can create and nondestructively edit the corresponding notes .
actions represent functions , which are not tied to specific notes , such as management and qa functions attending radiologists participate in the  wet reading  system by entering  review  notes . when entering a  review  ,
attending radiologists have four options to rate the level of disagreement with the  wet reading  note :  agree  ,  minor discrepancy  ,  major discrepancy  , and  good job  .
when there is a disagreement , attending radiologists provide correct interpretations and teaching points in the text of the review note .
the application displays these notes to the healthcare providers in a similar fashion to the  wet reading
reviews with  major discrepancy  appear on the worklist as bright - red buttons .
the application contains a quality assurance function , which allows residents to query the wet readings with which the attending radiologists disagreed , and to read the associated  review  notes .
this function is utilized both for individual learning and in the formal resident quality assurance conference , which is held at our institution every month .
the log of time - stamped information access , which our system generated , has also been very helpful in discussions of problem cases in the setting of hospital - wide trauma quality assurance conferences .
usually , a clear sequence of events ( including timing , content , and recipient of communication ) can be reconstructed from these logs .
the data collected in the radiologue application constitute records of the formal quality assurance proceedings , therefore , its discovery in the court of law is prohibited under california evidence code section  1157 .
in addition to security measures mandated by legislation governing protected health information ( hipaa ) , the application includes several additional measures to prevent accidental discovery of sensitive quality assurance information .
although the application utilizes identifying information to keep track of the cases , for the purposes of presentation , the identifying data are stripped .
also , outside the quality assurance context , the  wet reading  and  review 
notes are hidden from users when the final report for the radiological exam is entered into the medical record .
this final report , which is usually dictated by a resident or fellow and approved by an attending radiologist , constitutes the ultimate diagnostic result and the summary of preceding communication .
the application incorporates a dashboard , which displays workflow information derived from the access log ( fig . 
numbers of critical results , major disagreements with wet readings , and time delay in providing wet readings are tracked and graphed in real time .
because the application utilizes tracking data from the ris , the dashboard can calculate and display operational derivatives , such as throughput information .
patient - specific protected health information is stripped from all data used for management purposes . 

this feature allows real - time monitoring of key performance indicators gleaned or calculated from the action logging database .
dashboard is currently used to monitor the number of critical results , number of major discrepancies between resident wet reads and final results , and timing of the wet reads among other performance indicators dashboard page .
this feature allows real - time monitoring of key performance indicators gleaned or calculated from the action logging database .
dashboard is currently used to monitor the number of critical results , number of major discrepancies between resident wet reads and final results , and timing of the wet reads among other performance indicators as of this writing , radiologue has been in continuous operation for 19  months .
currently , the system has 1,822 users , including 149 radiologists ( residents rotating 14 at any one time , fellows rotating seven at any one time , and 14 attendings ) , 13 radiology managers ( which include chief technologists ) , and 1,650 clinicians ( residents , attendings , and nurses ) .
computerized systems for communication exchange are becoming widespread . by integrating a formal reporting system in the workflow of on - call residents ,
an electronic message - based system has been described for clinical communication with an off - site radiologist .
report an electronic communication among radiologists and support personnel for tracking technical problems   and for improving quality assurance procedures .
bland et al . describe a web - based application , which facilitates exchange of information among clinicians and scientists in research environment .
radiologists need to communicate with various members of the healthcare team , for a variety of purposes , under a variety of conditions .
therefore , we believe that there is a need for a unified electronic communication system that would be flexible enough to accommodate a multitude of uses . the radiologue system is our first attempt at creation of such an inclusive , pleuripotent system .
radiologue allows participation by multiple kinds of users ( doctors , nurses , and technologists ) in ways that can be tailored to their roles .
the system enables one to quickly and broadly disseminate important information , which is impossible to do through informal means , such as telephone , fax , or any other point - to - point means of communication .
further , radiologue allows documentation and tracking of information exchange , which result in better quality control and management decisions .
radiologue has already become an integral part of workflows used by radiologists , technologists , managers , and many clinicians . in implementing radiologue ,
radiologue was flexible enough to adapt to the existing ways of doing business , while offering new tools to improve efficiency and transparency of the processes .
as a result , all stakeholders could easily grasp the advantages of radiologue from the beginning , facilitating buy - in and simplifying implementation .
the aim of future development of radiologue is to facilitate and widen radiology - related communication .
modality - specific worklists will be displayed in the various patient care areas of the hospital ( nursing stations , emergency department , and scanning areas ) on wide - screen monitors .
we anticipate that such displays will result in better situational awareness by radiology and clinical staff , and ultimately in better modality throughput .
in so doing , we are exploring the effects of multidirectional communications between the radiology department and the rest of the healthcare enterprise .
our future efforts will make radiologue more standard - compliant and portable to other healthcare settings .
we are also working on an instant messaging module that will facilitate timely critical result distribution
. the legal status of information within radiologue is a matter of great concern and debate .
we believe that we have not sacrificed privacy and security of the protected health information in our striving for openness . in conjunction with our hospital administration , we have decided to treat all information in radiologue as a part of medical record .
similarly to the rest of the medical information , we treat the data used in our quality assurance program confidentially . in designing radiologue to be flexible and inclusive
, we sought to emulate the contemporary web - based technologies , which have collectively become known as
these applications , which include google , wikipedia , flickr and many others , encourage users to actively participate in creation of content . through inviting wide participation , these applications created additional value for their users , and thereby challenged the dominance of traditional means of publishing and communication .
our starting point is the realization that healthcare providers , who are outside the traditional communication loop , have important information to contribute to the radiological care of the patient .
these users also have important information needs that , if satisfied , can enhance the overall care of the patient .
the purpose of any medical communication systems is to break down barriers to effective information sharing .
it is therefore imperative that the information systems of the future be designed with sufficient flexibility , in order to avoid creating artificial barriers where none existed before .
 a web - based system for rapid multidirectional communication has been created in the radiology department at san francisco general hospital . 
 the system allows messaging among radiology attendings , residents , and technologists , as well as other members of the hospital community , such as emergency department physicians and nurses . instead of being tied to a particular workflow 
 , this system provides a flexible communication infrastructure which can be easily adapted for different functions and user roles . 
 the system has so far been configured to successfully support the standard  
 wet reading  
 workflow , to support marking and tracking of critical results , as well as multiple educational and quality improvement workflows . in the 19  months of operation , 
 the system has gained over 1,800 users ( virtually all providers at our institution ) , it has been accessed by radiologists over 39,000 times and by non - radiologists over 34,000 times . it has become an integral part of the radiology department operations and non - radiology clinical workflows . unlike most existing softwares , 
 our system is not a task - specific application , but a multipurpose communication system . 
 it is able to effectively accommodate multiple workflows and user roles through configuration ( without additional programming ) . 
 this flexibility has helped this system to be rapidly and widely adopted within our enterprise . the extended reach of the system enables improved monitoring and documentation of workflows , helping with management decision making , and quality assurance . 
 we report a successful radiology communication system based on the principles of flexibility and inclusiveness of users inside and outside the radiology department . 
Introduction
Methods
Results
Discussion