INFORMATICS SOLUTIONS TO REAL-WORLD PROBLEMS IN EMERGENCY RADIOLOGY

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INFORMATICS SOLUTIONS TO REAL-WORLD PROBLEMS IN
EMERGENCY RADIOLOGY

• TIM OCONNELL, M.ENG, M.D.

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DISCLOSURES

• Speakers fees, Siemens Healthcare
• Training sponsorship, Toshiba Canada
• President, Resolve Radiologic Ltd

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GOALS FOR TODAYS TALK

• a. Learn about some of the safety issues around
  the time-sensitive workflows in emergency
  radiology
• b. Understand how visual control systems can be
  used to improve radiologist awareness of workflow
  and safety issues in emergency radiology,
  including inter physician communication
• c. Learn how customized informatics solutions can
  be deployed in the radiology department settings
  to improve the quality and safety of care

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GOALS FOR TODAYS TALK

• Learn what is possible
• Im not saying this is what you should do
• Im saying some of this you can do

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DEFINITION VISUAL CONTROL

• Visual control is a business management technique
  employed where information is communicated by
  using visual signals
• This entails making problems, abnormalities, or
  deviations from standards visible to everyone

http//en.wikipedia.org/wiki/Visual_control
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BACKGROUND VISUAL CONTROL
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BACKGROUND VISUAL CONTROL
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ER RADIOLOGY 3 BIG CHALLENGES

• Get the right imaging for the right patient
• Get the right results to the right person
• Do both of the above in the right timeframe

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SIMPLE?
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BUT IN ANY GIVEN CASE
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WHAT WE NEED VS WHAT WE HAVE

• Need
• Easy to use, reliable, safe tools for
  communication of our complex workflow between the
  people who need information
• Have
• Pagers - 1950
• Fax machines - 1966
• Paper forms - 2nd century BC

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AND OUR PROCESSES ARE SIMPLE, RIGHT?
Ordering
Interpretation
Results
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NOT REALLY
Reiner, B. I. (2014). Hidden Costs of Poor Image
Quality A Radiologist's Perspective. Journal of
the American College of Radiology JACR, 11(10),
974978.
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COMPLEXITY RISK

• Taking too long to image a case
• Imaging a case incorrectly
• Taking too long before interpreting a case
• Communicating incorrect preliminary results
• Misunderstanding/miscommunication of results
• Distribution of results to wrong people

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NOT LIKE THE GM PLANT

• Traditional business analysis and solutions dont
  apply
• If a car assembly line gets backed up, the cars
  dont spontaneously explode
• But in ER radiology, delays to diagnosis or poor
  communication can mean increased morbidity or
  mortality

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PROBLEM LIST

• Order management
• Image study technique/monitoring
• Radiation Dose and Protocol Management
• Report management/workload
• Interpretation Quality and Efficiency
• Critical results communication

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ORDER MANAGEMENT
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ORDER MANAGEMENT
Reiner, B. I. (2014). Hidden Costs of Poor Image
Quality A Radiologist's Perspective. Journal of
the American College of Radiology JACR, 11(10),
974978.
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CURRENT STATE IN VGH ERORDER MANAGEMENT

• Requisition printer in the ER Reading Room
• All CT/US/MR studies require a telephone call
  from the EP
• After call, we get requisition, protocol it, and
  get it to CT/MR tech or trainee to perform US

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CURRENT STATE BENEFITSORDER MANAGEMENT

• No auto-protocoling
• Ensures radiologist is essential part of imaging
• Ensures we get a chance to ask questions about
  history
• Helps to ensure exam appropriateness
• Manual protocoling good for trainee teaching
  about complexities of protocoling

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PROBLEM LISTORDER MANAGEMENT

• EPs who forget to call us
• EPs who call us but forget to enter the order
• When we forget to protocol/deliver requisition

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SOLUTION SCHEDULED STUDIES DISPLAY
50 Monitor and mini PC - 1400 186 lines of code
- 600 (free!) Access to Modality Worklist Server
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SOLUTION ORDERED/SCHEDULED STUDIES DISPLAY

• Future state is to display both ordered and
  scheduled studies
• Pending access to RIS database
• Will avoid risk where EP forgets to call us

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STUDY TECHNIQUE /DOSE PROTOCOL QA
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STUDY TECHNIQUE/DOSE AND PROTOCOL QA
Reiner, B. I. (2014). Hidden Costs of Poor Image
Quality A Radiologist's Perspective. Journal of
the American College of Radiology JACR, 11(10),
974978.
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CURRENT STATE STUDY TECHNIQUE

• Real-time monitoring of ER CT and MR scan consoles

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BENEFITS REAL-TIME MONITORING

• Appendix checking with MRI tech for MR
  Appendicitis
• Position of ROI for CT Bolus Tracking, CT Scan
  Range
• Correct CT Protocol Selection
• Real-time Diagnoses we have seen
• Acute intracranial hemorrhage
• AAA Rupture
• Pneumothorax

• Aortic dissection
• Massive PE

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DOSE AND PROTOCOL QA

• Two tools
• Real-time CT Dose Database
• 70 display in reading room
• Offline CT Protocol Analyzer
• Interactive, web-based tool

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• Difference in dose due to
• Longer (Z-axis) topogram
• Larger patient

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Identical protocols, with different names - time
to clean up the scanner!
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IT CANT HAPPEN HERE
L-Spine CT, Brigham Womens Hospital, 2013
Total dose 4683.6 mGy 70mSv
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BUT IT DOES
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REAL-TIME DOSE DISPLAY BENEFITS

• Immediate feedback on old/improper protocol use
• Education about scan protocols and dose metrics
  for trainees
• Information for clinicians - shows real-time
  impacts of imaging

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OFFLINE PROTOCOL ANALYZER

• Interactive, web-based tool
• Allows user to upload CT protocol export from
  scanner
• User can then browse protocols

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OFFLINE PROTOCOL ANALYZER
Upload Screen
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OFFLINE PROTOCOL ANALYZER
List of uploaded protocols
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OFFLINE PROTOCOL ANALYZER
Scan Parameters
Reconstructions
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OFFLINE PROTOCOL ANALYZER BENEFITS

• Allows users to diagnose protocol issues without
  interrupting scanner workflow
• Educational tool for trainees
• For accreditation requirements for CT protocol
  reviews

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INTERPRETATION QUALITY AND EFFICIENCY
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INTERPRETATION EFFICIENCY
Reiner, B. I. (2014). Hidden Costs of Poor Image
Quality A Radiologist's Perspective. Journal of
the American College of Radiology JACR, 11(10),
974978.
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INTERPRETATION CURRENT STATE

• Always a drive to improve interpretation
  efficiency and quality in the ER setting
• Efficiency problem
• Prior images often not available
• Radiology reports can be time consuming to read
• Quality problem
• No good method to follow up future studies
• Self QA, learning, teaching cases

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PRIOR REPORTS NLP

• NLP Natural Language Processing
• Computer-based interpretation and understanding
  of text

NN NOUN, SINGULAR JJ ADJECTIVE IN PREPOSITION
NNS NOUN, PLURAL CC COORDINATING CONJUNCTION VBZ VERB, 3RD PERSON SINGULAR
VBP VERB, NON-3RD PERSON SINGULAR RB ADVERB VBN VERB, PAST PARTICIPLE
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Open Source NLP Toolkit
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FUTURE REPORTS TRACKER

• In interesting or uncertain cases
• Need a way to flag the case as interesting and
  automatically receive updates about the patient
  if/when future imaging occurs
• Benefits
• Education
• QA

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• Future improvement
• Track by body part
• Track surgical/discharge diagnoses

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REPORTING MANAGEMENT/WORKLOAD
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REPORTING MANAGEMENT
Reiner, B. I. (2014). Hidden Costs of Poor Image
Quality A Radiologist's Perspective. Journal of
the American College of Radiology JACR, 11(10),
974978.
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REPORTING MANAGEMENT CURRENT STATE

• At our institution
• Clinicians use Philips iSite
• Radiologists use Agfa Impax
• Clinicians have no informaiton about status of
  study interpretation or which radiologist is
  reading
• Problems with ER waiting on reports
• Problems with ER getting interpretations if
  studies read by non-ER radiologists

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REPORTING MANAGEMENT SOLUTION
ER Workload Tracker - on a 70 display in ER
reading room and in ER Nursing Station
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ER WORKLOAD TRACKING BOARD
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ER WORKLIST TRACKING BOARD
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REPORTING MANAGEMENT BENEFITS

• At-a-glance views of
• Current workload status (all red get to work!)
• Who is reading studies - can redirect ER
  physicians
• New studies from other sites

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CRITICAL RESULTS COMMUNICATION
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REPORTING MANAGEMENT
Reiner, B. I. (2014). Hidden Costs of Poor Image
Quality A Radiologist's Perspective. Journal of
the American College of Radiology JACR, 11(10),
974978.
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CRITICAL RESULTS CURRENT STATE

• Verbal reports from ER Radiologist or trainee for
  all CT/MRI/US studies
• CRs - ERP can leave an impression in Impax, but
  most use iSite and often do not leave anything

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CRITICAL RESULTS CURRENT STATE

• Problem 1
• Poor documentation by rads and trainees about
  delivery of critical results
• The responsible physician was informed at
  approximately 300pm
• No name
• No specific findings
• No method of communication documented
• Time may be incorrect, and may be important

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CRITICAL RESULTS CURRENT STATE

• Problem 2
• EPs claiming they werent told about incidental
  findings
• EPs who dont want to know about incidental
  findings
• Patients without primary care providers

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CAR STANDARD COMMUNICATION OF DIAGNOSTIC IMAGING
FINDINGS

• In some circumstances, such co-ordination may
  require direct communication to the referring
  physician in advance of the formal written
  report. These include
• The detection of conditions carrying the risk of
  acute morbidity and/or mortality which may
  require immediate case management decisions.
• The detection of disease sufficiently serious
  that it may require prompt notification of the
  patient, clinical evaluation or initiation of
  treatment.

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CRITICAL RESULTS CURRENT STATE

• Best effort at present, but getting contentious
  with EPs
• Need a way to reliably document
• What was communicated
• With whom
• When
• How
• In a way that always requires all of the above
  and can be queried and audited (i.e. not the
  radiology report)

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CRITICAL RESULTS INTERIM SOLUTION
One click from PACS Web-based Critical
Notification Record
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Similar to BWH ANCR
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CRITICAL RESULTS FUTURE STATE
Philips Intellispace Critical Findings Module
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SUMMARY

• Visual Control tools are effective for
  communication of scan information, workload and
  study status in emergency radiology environment,
  and can improve quality and safety
• Small, inexpensive informatics projects can work
  - you dont need to wait for big projects!
• Be wary of projects that boil the ocean

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SUMMARY

• Going forward still lots to do
• All of these projects require ongoing maintenance
• Biggest ongoing problem is the lack of hospital
  IT support
• Need
• Clinical decision support
• Electronic protocoling
• Electronic, secure result delivery

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THANK-YOU

• Dr. John Mayo, Department Head, Radiology,
  VGH/UBC Site
• Dr. Savvas Nicolaou, Section Head, Emergency
  Radiology, VGH
• Dr. Luck Louis, VGH ER Radiologist
• Dr. Patrick McLaughlin, VGH ER Radiologist
• Dr. Aaron Sodickson, BWH ER Radiologist
• Dr. Jeff Hu, PGY-1 Intern
• Cornell Ra, Jay Wong, and Roger MacDonald, VGH
  PACS IT Support

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Thank you!