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Imaging Services: United We Stand, Divided We Fall

July 5, 2010
by Joe Marion
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Happy Independence Day!

I’ve just started a new engagement with a client that is building toward new facilities for cardiac services. Part of the dialog involves issues with current facilities, in that procedures are split across radiology and cardiology services, which happen to have different PACS. For example, both cardiac and vascular surgeons may use the same rooms, but there is no commonality in the way studies are reported. Similarly, a cardiac catheterization procedure and an interventional radiology procedure may be done in the same room, but images are acquired into different systems and reports are generated differently. The consequence is that results are not consistently acquired into an EMR, necessitating a physician to have to look across multiple tabs to find the results for their patient.

At first blush, this seems like a technology issue, in that all studies are digital, and should be accessible in a common manner. However, the deeper I dig, the more it also becomes “turf” issues! Take for example the common practice of a Nuclear Stress exam. The nuclear imaging portion of the exam is commonly read by a radiologist, while the wave form documentation is reported by a cardiologist. In many institutions, each service area has independently implemented some form of PACS and reporting technology, which means portions of the exam live in different systems, and theoretically only come together in an EMR. The problem is that the EMR may be structured in such a manner that it separates clinical services.

More than likely, the reason behind these structural limitations is that they have been designed around departmental versus patient requirements. For the majority of cases, this may be workable, but certain cases may transcend departmental needs. Prior to digital images, the task was easier, in that there was only one physical media, or a copy was made, and the user viewed discrete pieces of information, usually in some chart or folder format.

Now that we are entering the age of a significant shift to electronic records, the file or folder must be translated to an electronic format, and electronics can be much less forgiving than physical media! One change in a digit or alpha character and they might as well be different patients!

Perhaps with the advent of electronic records, we also need to consider the need for a paradigm shift in the way the information is presented. After all, an electronic record should allow much more intelligence in the way output is formatted. Instead of presenting all of radiology’s results on a radiology tab, and all of cardiology’s results on a cardiology tab, why not present all relevant information for a particular order, or encounter in one location?

The relevance of such an approach is not limited to just the EMR – it needs to be pervasive across all imaging services. In cardiology, the advent of the hybrid room will necessitate a rethinking of workflow processes and systems. Take the case of an open heart procedure, where at the end of the surgery it would be helpful to image and measure the pressures to assure the patency of the grafts. In today’s world, the patient may end up being moved from a surgical suite to a cardiac catheterization lab. Most likely, this will be documented as two separate procedures. In a future hybrid room, it will be possible to perform the catheterization on the same equipment, and perhaps consider it a single procedure. This has implications for the hybrid room equipment, in that it would make sense to document the surgery and the catheterization at the same time.

Besides imaging procedures, centralized image and report management solutions are also essential. An EMR that is dependent on multiple data silos will be less manageable than one that relies on a centralized patient-centric image and report repository. A user would immediately see all information associated with a patient. And, presentation rules can impact how the information is accessed.

If the paradigm shifts to thinking of the study and not the service, then perhaps imaging and reporting systems can be designed around everyone’s needs, not just a service’s needs. Years ago as Product Planning Manager for CT, I marveled at the approach taken at the then Bowman Gray School of Medicine. While many other facilities standardized reading around sub-specialty, such as CT, Bowman Gray emphasized radiologists who read specific decease or anatomy, encompassing all imaging technologies.

Perhaps their thinking has helped shape my own viewpoints and they may very well have been ahead of their time. It seems as if an era may be upon us where cost and socio-political pressures warrant another look in terms of imaging and reporting systems. We need to understand the needs of the various practitioners and design systems and workflows around the total requirement.

This probably is easier to say than to do, as there is so much departmental infrastructure in place. But just as with my current engagement, if everyone takes a fresh perspective, perhaps we can make a difference. As usual, your viewpoints are welcome!