Imaging Systems: Better Care with Improved Efficiencies

If deployed well, health imaging systems can mean improved workflows, more cost- and time-efficient processes, fewer costly referrals and better care. Two providers share how recently implemented health imaging management systems in their cardiology departments and beyond shaped how they deliver care and some of the challenges and benefits along the way.

Smart imaging

Ohio State University (OSU) Wexner Medical Center developed its in-house Smart Imaging program after its health insurer, which covers 60,000 individuals, informed the center its “burn rate” for imaging was two to three times more than what was appropriate, says Richard D. White, MD, chairman of OSU’s radiology department and director of Smart Imaging.

One year after conceptualization and following several successful pilots, OSU rolled out Smart Imaging early this year aimed to eliminate unnecessary “high-end” exams (CT, MRI, SPECT/CT and PET/CT) and preventable risks from radiation and contrast exposure as well as to facilitate more appropriate care. “It provided some opportunities to streamline ordering, protocoling and scheduling of radiology studies and change no-show and confusion,” White explains.

The traditional pattern of ambulatory imaging ordering at OSU “was an energy sink for everyone concerned,” he says.

Before the Smart Imaging program, a physician would request an imaging examination and the study subsequently would be scheduled. Only after this point, close to the day and time of the examination, the patient would be reviewed for any potential contraindication. If any issues came up, then the patient often had to be rescheduled for a different examination or course of care.

This arrangement translated to high administrative costs, patient dissatisfaction and potential delays to imaging examinations, according to Luciano Prevedello, MD, MPH, chief of the division of imaging informatics at OSU. By establishing Smart Imaging, OSU sought to remove the energy drain by focusing activities on the front end.

The Start Imaging structure entails the integration of a front-line team of technologists, scheduling staff and radiologists with technical resources like imaging decision-support, says B. Selnur Erdal, PhD, director of radiology computing and imaging information sciences. In this workflow, the team receives an imaging request, and evaluates its appropriateness by running it through evidence-based electronic clinical decision support, based on American College of Radiology (ACR) appropriateness criteria.

Potentially inappropriate requests are flagged for review by radiologists who then discuss the case with ordering clinicians to further understand the clinical scenario and guide them through the ordering process. The team ultimately delineates other needed preparations, investigates any potential safety issues, finalizes the need for the imaging order and then performs the patient-personalized imaging scheduling.

“From what we have seen so far, it has been going very well. From my perspective, radiologists in this peer-to-peer appropriateness conversation are more embedded in the process of care,” says Prevedello.

“We have demonstrated the value-added role of the radiologist,” agrees White. For example, he cites a case where a patient with arrhythmogenic right ventricular dysplasia who had a good score on the ACR appropriateness criteria for a cardiac MR imaging test did not have the procedure after the team discovered that the patient had a pacemaker. Instead of the back-and-forth in the old system, or referring the patient back to his physician in a “whac-a-mole,” style, as White describes it, the team determined early on that the patient should have a CT scan.

Because not all conditions are covered under ACR appropriateness criteria, radiologists also may use Smart Imaging to help identify gaps or propose new criteria.

Image sharing

Boston Children’s Hospital (BCH), the pediatric teaching hospital of Harvard Medical School, rolled out imaging sharing technology in 2010. The IT department first implemented the program in the orthopedics and sports medicine department, and then others, including radiology and cardiology.

The technology allows patients with CDs to upload their images on the spot and have them available to clinicians through a cloud-based portal. In the past, patients brought in CDs, and IT staff uploaded them in an image service center prior to sending them back to patients. That practice created security concerns if the CD accidentally ended up at the wrong address, says William Tellier, BCH’s RIS manager.

The latest imaging technology system allows outside referring hospitals and medical clinics and patients themselves to upload images on an online platform. About 3,000 CDs per month are seamlessly uploaded into the cloud, which is managed by the vendor.

BCH reviews many cases from out of state or through its international health services department. Outside physicians receive a user name and password that, for security purposes, is good for one week. After a log-in, they send the images to the cloud. The hospital is notified, and then the image is available within the EMR.

An image sent through the cloud allows physicians to rule out or confirm diagnoses, which has been a “huge benefit,” says Adam Lipson, team lead cardiovascular picture archiving and communications system (PACS) manager.

“Within 10 minutes, we have images available,” says Tellier, and radiologists can view them to give their second opinion on a diagnosis or refer a patient to the hospital. This can mean a world of difference for trauma surgeons or physicians who can access images in emergency scenarios.

For example, a 1-year old girl fell down the stairs and the local emergency department (ED) transferred images using the system. An epidural hematoma was discovered, allowing the surgeon to prepare for the procedure before the patient arrived.

“She skipped the ED, skipped the imaging process and went directly into the operating room and had a successful operation,” Tellier says, adding that the attending surgeon “was convinced that it would not have turned out well if he did not have the images. It was a life-or-death situation.”

The main advantages seen in the cardiology department is swifter decisions on whether a patient transfer is warranted. Prospective patients receive a link from BCH and upload their study, which becomes directly available to the specialist in the EMR.

Lipson says if a child is in the intensive care unit, BCH can access images to determine if previous studies have taken place and assess radiation exposure. “It has had a huge positive impact on children’s care and the costs overall,” he says.

However, implementation has not occurred without challenges. In the cardiology space, the setup by the vendor does not necessarily reflect the cardiologist’s workflow. “Many physicians want to do everything themselves, and some want to push it off on an administrative assistant. Combining those two paradigms has been challenging, particularly when it comes to user education,” Lipson says.

Also, glitches may occur when a patient or a different hospital or clinic uploads an image. Lipson says the technology is challenging to troubleshoot remotely, and discovering who owns the problem is difficult. “We don’t have any control over a patient’s PC or Mac, and we don’t wish to assume control,” he says.

If a hospital does not authorize physicians to update Java applets on their computers, then they may have difficulty transmitting images that are not non-dicom, which delays care, he adds. These issues remain to be worked out.

As technical and workflow issues get ironed out, clinicians will increasingly see the benefits these systems have on care, proponents say. In the healthcare field, where waste-reduction in time, energy and financial resources is increasingly critical, streamlining workflows with health imaging technologies can not only help hospitals with their bottom line, but also facilitate more appropriate care.