Outside Medical Image CD Systems—It’s All About the Workflow

The Real Problem

The real problem is that while these systems are helpful by filling a gap in the market and addresses a real problem (what to do and how to manage outside medical images), they should not have to exist.  They are separate from the hospital or practice PACS system and inject fragmentation into clinician workflow. For example, “patient A” arrives for a pulmonary appointment with a CD containing a chest X-Ray that was done at another facility.  Ninety percent of the time the pulmonologist is likely going to flag this study as clinically relevant and store it in the hospital PACS or VNA. The workflow to make that happen is a collection of manual and electronic handoffs as the image is passed from system to system until it properly arrives in its permanent archive home. You can argue that there are ways to automate much/all of these steps but most facilities are not nearly that mature with this technology and the fact remains that multiple image management systems are injected into clinician workflows which always increases the opportunities for gaps to cause problems.  

If we now refer back to “patient A”: The physician logs into the outside CD import system and finds the study on the CD. The physician then wants to see if the patient had any relevant prior studies for comparative purposes. In order to do this, the physician needs to log into the PACS and find the patient (assuming they were a prior patient) and bring up the studies. Since the outside CD studies are not yet in the PACS, the physician must navigate between two workstations to look at the old and new images. If the outside CD study is deemed clinically relevant, it needs to be stored in the PACS or VNA. A clinical order must be created in the EMR, passed to the radiology information system (RIS), which is interfaced to the PACS, and assigns the relevant accession number uniquely identify the outside CD study. Then back-office staff use a work-list to manually label the imported study and pushes it to the PACS or VNA.  This may not be the exact same situation at every hospital but I bet it is pretty close. This is not viewed as a desired workflow by any clinician.

If you ask any clinician involved with importing studies from outside entities (and you should), they will tell you that the PACS or VNA should have the ability to upload studies from an outside CD, allow for re-labeling and storage in the PACS or VNA without requiring circus-like maneuvers to make this happen. It should take minutes, not hours to occur, with minimal manual intervention and effort.

Another interesting issue that we’ve run across is that the systems that manage outside CDs look a lot like a PACS. You can do many of the basic functions with images like you would on a PACS but it is not meant to be for diagnostic review. It’s not diagnostic quality for a good reason. If it were, then it would fall under elevated FDA regulatory review and would be a huge burden on the vendor, increase their costs, introduce delays for upgrades, new products, etc. Just speculation, but I wonder how many of these niche CD import utility vendors would remain in the market if that were to happen. The fact that these CD import utility products are not intended to function like a PACS creates a perception problem with physicians because the systems “looks” like a PACS, it kind of “acts” like a PACS, but “this is not as good our PACS.” It is a re-affirmation that in a perfect world, we would not need a separate solution to handle images from outside CDs but until we get closer to a perfect world, these will remain real issues that need to be managed.

Final message: Anyone considering implementing an outside CD import system should pay close attention to workflow issues and be prepared to manage physician and radiology department expectations.

Jim Beinlich is the Associate Chief Information Officer of Entity Services with the Penn Medicine-University of Pennsylvania Health System, a $4.3 billion health care provider organization consisting of over 2,000 physicians providing services to the Hospital of the University of Pennsylvania, Penn Presbyterian Medical Center, Pennsylvania Hospital and the health system network that serves the city of Philadelphia, the surrounding five county area and parts of southern New Jersey. He is a certified Project Management Professional and holds an MBA in Health Care Management from Widener University.  He has over 20 years of experience in Healthcare Information Service operations and consulting.