Radiology Practice Efficiency

Successful modern workstations must be a subtle combination of a great many attributes as well as provide intelligent display of integrated software applications. In the past this seemed like a tall order, but in today’s environment it can be a reality. The business environment surrounding the current imaging market is not the most optimistic: dramatically decreasing reimbursement combined with increasing costs. Until this market trend stabilizes or less likely reverses, there is a critical need for efficiency throughout the image lifecycle (ordering, scheduling, acquisition, interpretation, report distribution/consumption and billing) and intuitive workstations can have their greatest impact in the image interpretation segment. 

Modern workstations can be judged on a great many things, however, two must first be considered above the others. The basics are stability and speed. Without these, efficiency can be lost on downtime rendering other higher level features almost useless. As a result, the server side applications which are displayed on these workstations much have this as a prerequisite. After this, the user interface is key. Hopefully, the radiologist will have the pleasure of working with a “role-defined” user interface. To me, the goal of the intelligent workstation is to allow the user to focus on image interpretation and minimize distractions created by report generation and task organization. The “role-defined'“ UI is specifically designed to do just that. It should achieve what is required for the task at hand at least 90% of the time with what is located on the desktop and the rest being one click away. This can be achieved if the UI is not cluttered with the tasks/options that that are not pertinent to that user’s role within that system, such as found in a Radiology Information System (RIS) or Picture Archiving and Communication Systems (PACS). 

Typically, the radiologist’s Image Interpretation Suite (IIS) will contain functionality of a RIS, PACS, speech recognition (SR), Electronic Medical Record (EMR) and advanced imaging applications (AIA). Again, the role defined functionality and display are critical for the radiologist to achieve efficiency when interacting with so many applications at once. If the IIS is organized and integrated properly, the radiologist’s job can be distilled down to just study interpretation. In our practice, we utilize a radiologist portal which provides a display of the role based information and functionality located within the RIS, EMR and speech recognition applications. Additional functionality in this portal is provided by embedding web links to other decision support tools. This radiologist portal is then tightly integrated into the PACS to provide the appearance of a single system. The PACS also contains integrated advanced viewing applications that are incredibly useful for interpretation of Molecular, Coronary and Colonography examinations. 

The radiologist portal utilized in our practice has been specifically designed to optimize a radiologist’s workflow by providing integrated display of information contained in the RIS and EMR combined with the functionality located within the speech recognition application. In addition, the speech recognition application is fully integrated into the RIS. This provides an advanced level of synergy for exam workflow and report generation. Exams that are ready to be interpreted or consumed are located within virtual reading rooms (VRR). Each is designed with subspecialty interpretation in mind; however, each has the flexibility to rotate different radiologists into each of the two FTE slots assigned to each room. To accommodate for the normal ebb and tide of examinations at individual locations each virtual reading room has some overlap with another. Lastly, what is located in the VRR is only partially based upon your physical location. At any time the radiologist can switch VRRs or view all exams, practice wide, ready for consumption. This enterprise wide distribution of examinations optimizes subspecialty interpretation without compromising efficiency. When an exam is chosen either manually or automatically after interpretation of the previous exam, the speech recognition application is immediately triggered. As there is full RIS integration, a template that is designed on a modular dictation strategy is automatically placed in the “current dictation” field that is appropriate to the examination being interpreted. These templates and which one is automatically inserted are user defined. The interpreting radiologist must then only dictate what is abnormal on the examination to generate the report. This can be further streamlined by using shortcuts to populate the description of the abnormality. The rest of the report contains the users chosen language for a normal or negative description of the appropriate anatomy. By eliminating repetitive descriptions of normal anatomy efficiency is gained as well as decreasing the number of corrections or edits to the translated text. Study and patient information as well as date and time are automatically added to the report via the RIS. Despite the high accuracy of today’s speech recognition systems, the less you can the dictate for translation the better. In our group, 90% of the radiologists are 100% self edit with the remaining 10% utilizing a transcriptionist less than half of the time. Self edit workflow has had a dramatic impact on the service, marketability and financial aspects of our practice. Besides the financial implications of fewer transcriptionists there has been dramatic clinical benefit as our report turnaround time is less than one hour which in turn has contributed to our practice growth in a competitive environment.

Our PACS is optimized for image interpretation and manipulation. The workflow intelligence, old reports and speech recognition integration is all contained within the RIS. In this way, the PACS can focus on image display and manipulation for the radiologist to formulate an impression. In today’s market almost all PACS venders supply a similar list of features. As the “feature war” of the past 6 years has matured, the focus has shifted to integration. Besides this, what now appears to be most important in a modern PACS is immediate access to images across the enterprise. This “anything from anywhere” option provided by the PACS allows our radiologist portal to effectively utilize its workflow intelligence. This synergy provides a greater efficiency in interpretation than either could provide alone.

Advanced imaging applications are integrated into the PACS either as a server side or thicker mixed client partially located on the single PC of the workstation. In either case, a radiologist is no longer tied to a dedicated Advanced Workstation for these applications. As all this functionality is located within our main workstation, the idea of reading “anything from anywhere” in the enterprise can be achieved. This integration is critical when interpreting PET/CT examinations which have fusion imaging, multiple time points and comparisons with different modalities that are necessary to provide excellent service regarding cancer care. This also can facilitate second opinions as all working radiologists have equal access to the same AIA options. Again, improving the quality of care and improving efficiency.

From an ergonomic standpoint in our practice, a four monitor workstation with a single PC is the standard. The radiologist portal is displayed on a single monitor 2MP monitor on the left of the workstation. The next two monitors, located in the center are reserved for PACS display. These monitors are medical grade with three megapixels in resolution. Finally, a fourth monitor is reserved for integrated advanced viewing applications. In our practice this functionality is positioned from left to right as the typical user will utilize a workflow of task management, image interpretation followed by or with simultaneous report generation. This organization of application display appears to minimize eye movement about the four workstation monitors. It also seems to fit naturally as we read the English language from left to right and so we move through our interpretation workflow from left to right. In addition to monitor configuration, the workstation also must have optimal ergonomics. Much literature exists from within and without the medical industry regarding these features. I feel the most important factor is flexibility. Without this, the physical layout of the workstation will not be able to support the different physical dimensions and work habits of the radiologists. In our practice, we utilize a motorized two-tier desktop. The desktop in the background houses the four monitors on articulating arms, while the desktop in the foreground contains our keyboard, pointing devices and phone. These are all connected to the single PC via Bluetooth© technology. Both desktops can accommodate the standing and sitting height of all ten of our radiologists. A high quality chair rounds out the physical space of the workstation.

A radiologist workstation should be organized and balanced around three principals: Simplicity, Flexibility and Functionality. When these are in sync the user is not distracted by the immense functionality of the applications located at the workstation. In our practice we have experienced 15% growth of imaging volume since deployment of this enterprise wide system. In addition this image volume has been interpreted with one less radiologist without increasing our number or length of workdays. Combined, the system employed has provided approximately 27% efficiency to our report generation while dramatically increasing the service provided to our patients and referring doctors. This has been instrumental to our growth as a practice in a competitive environment as well as help ease the impact of the recent deficit reduction act.

Attributes of an Intelligent Workstation

• Reliability
• Integration
• Functionality
• Speed
• Role-defined user interface
• Ergonomics
• Display format
• Business Intelligence
• Workflow Intelligence