Systems that read and manage outside CDs containing medical image studies (X-Ray, CT, Ultrasound, etc.) are a real benefit to healthcare users who have been challenged with issues associated with the CDs patients bring along with them to hospital and office visits. Many times CDs are difficult to handle because the imaging systems used to burn the CDs are from different manufacturers or use different software to write to the CD; and some require different readers. There are also challenges with managing the images once you can actually see them on the CD. Once read and uploaded, users need to:
- Identify and tag studies with their own institutional Identifiers (medical record number and order or accession number);
- Electronically share images with other clinicians;
- View images with basics PACS-like features using a single viewer;
- Operate in a HIPAA-compliant manner; and
- Push studies to the hospital PACS that require permanent storage.
To address these challenges, a number of vendors and products have cropped up in the past several years to allow uploading, viewing, and managing of CDs containing medical images brought by patients to the hospital or physician’s office. Implementing one of these systems is relatively easy and can offer a fairly rapid deployment (sometimes only a few months). What you learn pretty quickly is that there can be profound impacts on the workflow in your office and/or hospital departments for your front office staff, medical assistants, physicians, radiology, and IT. Oh, and don’t forget all of the “ologies” besides radiology that handle outside CDs from patients and the unique challenges this presents to their operations. Understanding where these systems fit [they are not a replacement for your official picture archiving and communication (PACS) systems] in your clinical and billing workflow is the key to a successful implementation.
How It Works
The process for uploading the images, viewing, and basic management is fairly straightforward:
- Patient brings the CD to the hospital department or physician practice;
- Practice/hospital staff (usually front desk) uploads the studies to an electronic inbox;
- Physicians view the studies using the standard image viewer provided by the system; and
- Physician tags the relevant studies (e.g., as reference for some current or future exam, or studies that require a “second read” from a radiologist), and initiates the archiving of the selected studies in either your primary PACS or vendor neutral archive (VNA).
Reality of the Workflow 'Beyond the Basics'
There are processes beyond the basics that are required due to the integration of workflows for permanent tagging and storage of images that are deemed clinically relevant and need to be kept. There are also requirements for billing purposes (second reads) as well as PACS integration requirements (“need an accession number from PACS”) depending on your facilities workflow and policies/procedures. This is where things can get a little complicated and can be a source of confusion and frustration.
- Depending on the requirements of the hospital or practice, and whether or not billing is required for second reads, a clinical order in the electronic medical record (EMR) may be required to associate the outside study with the PACS system. This might sound easy but it is not:
- While basic clinical staff can place an order in the EMR, only authorized physicians/clinicians can “sign” the order; and
- This manual step requires the attention of a busy provider and at best it is not their favorite task to complete and at worst can be viewed as simply a waste of their time.
- Back office staff (usually in the Radiology department) use work-lists to associate the studies queued up for long term storage in the PACS or VNA with the order numbers, accession numbers, etc.
- This represents another manual process that needs to be completed by a different operational group. This is not an instant turnaround activity.
The Other 'Ologies'
The workflow complications for medical images can be challenging but consider that most radiology departments are generally architected to handle these complications based on years of experience with PACS and the challenges of image management. Other departments do not generally have this rich background in image management.
Cardiology has become a major player in not only medical image but now medical image video generation and associated storage. Patients bring ultrasounds and echo-cardiogram images and video on CD. Depending on your hospital or practice policies, those images may have to be archived in the cardiology PACS (not the radiology PACS). This is certainly doable, but usually does not bring with it the same rigor provide by a more sophisticated radiology workflow, not to mention an alternate destination now must be created and supported from the outside CD system to a second PACS.
Most other “ologies” such as dermatology, ophthalmology, neurology, and others usually have import mechanisms into their image stores (they may or may not be a PACS). While this department niche approach improves department workflow, it creates an environment where long term outside medical image storage is fragmented and difficult to manage.
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.