en en fi en en en en en fr en en en en en en en en en en en en en en en en en en en en en he en en en en en en en en en en en ro it en eu en en en en en en en en en en en en en en en en en en en en en en en en en en en en en en en en en en it en en en en en en en en en en en
The heartbeat of today’s radiology department continues to be the flow of information. Radiologists at Cincinnati Children’s Hospital in Ohio describe how radiology informatics have worked to improve this process by identifying and reducing inefficiency through continuous improvement led by radiology informaticists. They offer suggestions that have worked at their hospital in an article published in Pediatric Radiology.
Standardization, an essential element of quality improvement, should be established as much as possible at the beginning of implementing any new element of an information system. Workflow needs to be designed to be as lean as possibly by automating routine information flow and eliminating every possible aspect of individualized work.
To streamline the radiology ordering process, the department initially standardized its naming schema. Each order starts with the modality, followed by the body part, special instructions, and the side of the body (if applicable). The next project was to identify and eliminate confusing orders. All order names that caused confusion or were frequently misordered were renamed. A thesaurus was also created and integrated with the hospital’s electronic medical record in order to help providers find orders that could be identified by multiple names or abbreviations, such as CT PA and CT Pulmonary Angiogram. In this scenario, when a physician enters a “synonym” name, the correct order name would be displayed.
Combination orders were created to eliminate the need for a physician to order exams individually, such as a computed tomography (CT) scan of the chest, abdomen and pelvis. Because combination orders meant that studies no longer had to be linked, this workflow also helped to make the technologist performing the exam and the radiologist dictating it more efficient. It also made the study more likely to be billed correctly. The major limitation of combination orders is that they do not work well if a study needs to be interpreted by multiple divisions.
The department also created specialty orders, defined as one order that refers to one or more CPT codes and where the order name itself refers to a particular indication or protocol, such as MR enterography. Creation of specialty orders enabled the department to target specific studies with specific protocols requested by individual physicians by placing the order on a divisional preference list. Additionally, structured report templates were created for each specialty order.
Alexander J. Towbin, MD, director of radiology informatics, explained that to prevent new order categories from multiplying, any new order request must be processed through a multi-step approval process to ensure the principles of necessity and efficiency are observed when new orders are designed. These must be a demonstrated clinical or business need, such as a unique billing or reporting option or the creation of a new service.
Finally, certain orders were created and only made available for technologists to place. This class of orders was reserved for rarely used orders that are often misordered such as a computed tomography (CT) examination of the chest without and with contrast. By making the orders only available to the technologist, the risk of a misordered exam is eliminated. In the rare instance when this type of order is needed, it is identified through the protocoling process and changed by the technologist to the correct order prior to scanning. A side benefit of this process is that it encourages discussion between the ordering physician and radiologists so that the most appropriate exam can be ordered for the patient.
Standardizing patient information access
The department has created processes by which it can obtain patient information needed to perform and interpret a study. An example of this is how the department defaults the order priority for the emergency department studies to ASAP instead of routine or STAT. Defaulting the order priority helps to ensure that emergency department studies are identified, performed, and interpreted in a timely manner.
Another example of this type of efficiency is seen in how information flows from the electronic order, to the technologist control sheet, and finally directly into the dictated radiology report. The electronic medical record (EMR) even has a field for the technologists to enter information. The technologist-derived clinical history is also pulled directly into the dictated report.
Protocoling, structured reporting, and communicating critical results
Protocoling an exam is now an electronic rather than a paper based process. Historically, this process had been laborious, often requiring multiple changes. An electronic status board and protocoling before the examination is scheduled allows greater opportunity to discuss the exam with the ordering physician and to make changes in a more efficient manner.
Cincinnati Children’s Hospital was an early adopter of structured reporting templates and now has approximately 450 department-standard structured reports in use, nearly one for every type of order. The radiology department has also created a standardized process for critical results reporting. Customer service representatives convey and document the critical results reporting process, and facilitate communication between interpreting radiologist and ordering physician when needed.
Implementation, improvement, and expansion of processes that increase efficiency is a team effort, led by a “systems thinking” architect. Practicing radiologists who are also informaticists with an understanding of information flow are ideal for this leadership position. A system architect can manage the process with a coherent vision rather than have multiple information technology systems be cobbled together. The system architect also must be empowered to make decisions for the good of the department. In this position, the system architect can directly observe department activities and freely receive input from any individual inside and/or interacting with the radiology department.
Towbin AJ, Perry LA, Larson DB. Improving efficiency in the radiology department. Ped Radiol. 2017 47; 7: 783-792.