Repercusión de un sistema de reconocimiento del habla integrado en un PACS/RIS con respecto al tiempo invertido en elaborar y poner a disposición los informes radiológicos / Impact of a PACS/RIS-integrated speech recognition system on the time expenditure in completing and making available radiology reports

Purpose: Quantification of the impact of a PACS/RIS-integrated speech recognition system (SRS) on the time expenditure for radiology reporting and on hospital-wide report availability (RA) in a university institution. Material and methods: In a prospective pilot study, the following parameters were assessed for 669 radiographic examinations (CR): 1. time requirement per report dictation (TED: dictation time (s)/number of images (examination) x number of words (report)) with either a combination of PACS/ tape-based dictation (TD: analog dictation device/ minicassette/transcription) or PACS/RIS/speech recognition system(RR: remote recognition/transcription and OR: online recognition/self-correction by radiologist), respectively, and 2. the ReportTur-naround Time (RTT) as the time interval from the entry of the first image into the PACS to the available RIS/HIS report. Two equal time periods were chosen retrospectively from the RIS database: 11/2002-2/2003 (only TD) and 11/2003-2/2004 (only RR or OR with speech recognition system (SRS)). The midterm (> 24 h, 24 h intervals) and short-term (< 24 h, 1 h intervals) RA after examination completion were calculated for all modalities and for CR, CT, MR and XA/DS separately. The relative increase in the mid-term RA (RIMRA: related to total number of examinations in each time period) and increase in the short-term RA (ISRA: ratio of available reports during the 1st to 24th hour) were calculated. Results: Prospectively there was a significant difference between TD/RR/OR (n = 151/257/261) regarding mean TED (0.44/0.54/0.62 s (per word and image)) and mean RTT.

Objetivo: Cuantificar la repercusión de un sistema de reconocimiento del habla integrado en un PACS/RIS en el tiempo invertido en los informes radiológicos y su disponibilidad en una Clínica Universitaria. Material y métodos: Estudio piloto prospectivo; en 669 radiografías se registró el tiempo invertido por dictado con cinta y sistemas PACS/RIS de reconocimiento (dictado por lotes o dictado en línea) y el Report Turnaround Time, intervalo de tiempo desde la introducción de imagen en PACS hasta tener informe disponible en RIS/CIS. En análisis retrospectivo de base de datos de RIS se estudió 11/2002-02/2003 y 11/2003-02/2004. Se calculó la media y el aumento relativo de la disponibilidad de informes a mediano y corto plazo tras la finalización del estudio. Resultados: Se observaron importantes diferencias en el tiempo invertido para cada modalidad (0,44/0,54/0,62 s por palabra e imagen) y del RTT medio (10,47/6,65/1,27 h). Se evaluaron retrospectivamente 37.898/39.680 informes de los períodos mencionados. En CR/TC, se observó un aumento medio del 20 por ciento en la disponibilidad de informes a corto plazo y en todas las modalidades fue más del triple en las primeras 24 h. En el caso de CR/TC/RM, el primer día hubo un aumento máximo de la disponibilidad a mediano plazo (factor 3,1/5,8/4,0) y en el caso de XA/DS, en el segundo día (factor 2,0). Conclusión: Cuando se utiliza un sistema de reconocimiento del habla se modifica el flujo de trabajo y se invierte inicialmente más tiempo para la elaboración de informes. Los sistemas de reconocimiento integrados en PACS/RIS mejoran considerablemente la disponibilidad de los informes a corto y mediano plazo, redundando en la calidad de la atención de los pacientes.

[Impact of a PACS/RIS-integrated speech recognition system on radiology reporting time and report availability]. / Einfluss eines PACS-/RIS-integrierten Spracherkennungssystems auf den Zeitaufwand der Erstellung und die Verfügbarkeit radiologischer Befunde.

PURPOSE: Quantification of the impact of a PACS/RIS-integrated speech recognition system (SRS) on the time expenditure for radiology reporting and on hospital-wide report availability (RA) in a university institution. MATERIAL AND METHODS: In a prospective pilot study, the following parameters were assessed for 669 radiographic examinations (CR): 1. time requirement per report dictation (TED: dictation time (s)/number of images [examination] x number of words [report]) with either a combination of PACS/tape-based dictation (TD: analog dictation device/mini-cassette/transcription) or PACS/RIS/speech recognition system (RR: remote recognition/transcription and OR: online recognition/self-correction by radiologist), respectively, and 2. the Report Turnaround Time (RTT) as the time interval from the entry of the first image into the PACS to the available RIS/HIS report. Two equal time periods were chosen retrospectively from the RIS database: 11/2002 - 2/2003 (only TD) and 11/2003 - 2/2004 (only RR or OR with speech recognition system [SRS]). The mid-term (> or = 24 h, 24 h intervals) and short-term (< 24 h, 1 h intervals) RA after examination completion were calculated for all modalities and for CR, CT, MR and XA/DS separately. The relative increase in the mid-term RA (RIMRA: related to total number of examinations in each time period) and increase in the short-term RA (ISRA: ratio of available reports during the 1st to 24th hour) were calculated. RESULTS: Prospectively, there was a significant difference between TD/RR/OR (n = 151/257/261) regarding mean TED (0.44/0.54/0.62 s [per word and image]) and mean RTT (10.47/6.65/1.27 h), respectively. Retrospectively, 37 898/39 680 reports were computed from the RIS database for the time periods of 11/2002 - 2/2003 and 11/2003 - 2/2004. For CR/CT there was a shift of the short-term RA to the first 6 hours after examination completion (mean cumulative RA 20 % higher) with a more than three-fold increase in the total number of available reports within 24 hours (all modalities). The RIMRA for CR/CT/MR was 3.1/5.8/4.0 in the first 24 hours, and 2.0 for XA/DS in the second 24-hour interval. CONCLUSION: In comparison to tape-based dictation, an SRS results in a significantly higher primary time expenditure and a modified report dictation workflow. In a university institution, a PACS/RIS-integrated SRS achieves a marked improvement in both short- and mid-term RA which eventually results in an improvement in patient care.

[Speech recognition: impact on workflow and report availability]. / Spracherkennung: Auswirkung auf Workflow und Befundverfügbarkeit.

With ongoing technical refinements speech recognition systems (SRS) are becoming an increasingly attractive alternative to traditional methods of preparing and transcribing medical reports. The two main components of any SRS are the acoustic model and the language model. Features of modern SRS with continuous speech recognition are macros with individually definable texts and report templates as well as the option to navigate in a text or to control SRS or RIS functions by speech recognition. The best benefit from SRS can be obtained if it is integrated into a RIS/RIS-PACS installation. Report availability and time efficiency of the reporting process (related to recognition rate, time expenditure for editing and correcting a report) are the principal determinants of the clinical performance of any SRS. For practical purposes the recognition rate is estimated by the error rate (unit "word"). Error rates range from 4 to 28%. Roughly 20% of them are errors in the vocabulary which may result in clinically relevant misinterpretation. It is thus mandatory to thoroughly correct any transcribed text as well as to continuously train and adapt the SRS vocabulary. The implementation of SRS dramatically improves report availability. This is most pronounced for CT and CR. However, the individual time expenditure for (SRS-based) reporting increased by 20-25% (CR) and according to literature data there is an increase by 30% for CT and MRI. The extent to which the transcription staff profits from SRS depends largely on its qualification. Online dictation implies a workload shift from the transcription staff to the reporting radiologist.

[Possibilities for workflow optimization in radiology departments beyond RIS and PACS]. / Möglichkeiten der Optimierung des Workflows in radiologischen Abteilungen jenseits von RIS und PACS.

Technological progress and the rising cost pressure on the healthcare system have led to a drastic change in the work environment of radiologists today. The pervasive demand for workflow optimization and increased efficiency of its activities raises the question of whether by employment of electronic systems, such as RIS and PACS, the potentials of digital technology are sufficiently used to fulfil this demand. This report describes the tasks and structures in radiology departments, which so far are only insufficiently supported by commercially available electronic systems but are nevertheless substantial. We developed and employed a web-based, integrated workplace system, which simplifies many daily tasks of departmental organization and administration apart from well-established tasks of documentation. Furthermore, we analyzed the effects exerted on departmental workflow by employment of this system for 3 years.

[PACS: storage and retrieval of digital radiological image data]. / PACS: Speicherung und Abruf digitaler radiologischer Bilddaten.

BACKGROUND: Efficient handling of both picture archiving and retrieval is a crucial factor when new PACS installations as well as technical upgrades are planned. MATERIALS AND METHODS: For a large PACS installation for 200 actual studies, the number, modality,and body region of available priors were evaluated. In addition, image access time of 100 CT studies from hard disk (RAID), magneto-optic disk (MOD), and tape archives (TAPE) were accessed. RESULTS: For current examinations priors existed in 61.1% with an averaged quantity of 7.7 studies. Thereof 56.3% were within 0-3 months, 84.9% within 12 months, 91.7% within 24 months, and 96.2% within 36 months. On average, access to images from the hard disk cache was more than 100 times faster then from MOD or TAPE. CONCLUSION: Since only PACS RAID provides online image access, at least current imaging of the past 12 months should be available from cache. An accurate prefetching mechanism facilitates effective use of the expensive online cache area. For that, however, close interaction of PACS, RIS, and KIS is an indispensable prerequisite.

[DRG and OPS-301: effects on the acquisition performance in radiology]. / DRG und OPS-301: Auswirkungen auf die Leistungserfassung in der Radiologie.

Reimbursement for inpatient services rendered based on comparable daily care rates, case-based flat rates, and special fees as practiced until now has been replaced by the system of diagnosis-related groups. Up until 2004, operation and procedure system (OPS 301) codes could be processed completely automatically by appropriate adaptation of the radiology information system (RIS). Because of further differentiation of OPS codes in the 2005 version, it is no longer possible to unambiguously determine OPS codes automatically. Our goal was to fulfill these additional requirements with as little extra effort as possible. In 36 of 2138 procedures during an observation period of 12 days, i.e., 4/day, manual input on the part of the radiology technical assistant and quality assurance by the diagnosing physician were necessary. This is only needed in complicated procedures for which the minor added effort is negligible in comparison to the entire effort expended for the procedure. We were thus able to achieve the goal of near automation of ascertaining OPS codes.

[Recommendations for the selection of storage media for archiving digital radiological image data based on the comparison of retrieval times at different PACS archive levels]. / Empfehlungen zur Medienwahl für die Archivierung radiologischer Bilddaten auf der Basis einer Analyse der Zugriffszeiten auf verschiedene PACS-Archivebenen.

PURPOSE: Recommendations for archiving digital radiological image data based on the comparison of retrieval times for different PACS archive levels. MATERIALS AND METHODS: For a large PACS installation (Agfa Impax, Release 4.1), image retrieval times for radiological standard examinations (chest radiographs with 2, MRI with 250, CT with 100 and 1000 images; n = 120, each) from hard disk array, magneto-optical disk (MOD), and magnetic tape archives (TAPE) were examined in high and low network traffic load. RESULTS: Even large CT examinations (1000 images) were available from hard disk arrays within 4.0 +/- 0.8 s, smaller studies within 1.8 +/- 0.3 s. Radiographic image retrieval from MOD (30 +/- 4.7 s) was more then 50 % faster than from TAPE. For typical cross-sectional studies, the velocity gain amounted to 19 %. For both technologies, no significant difference was found for large CT examinations (651 +/- 144 s). For high and low network traffic load scenarios, image retrieval times from hard disk, MOD, and TAPE archives increased by 87 %, 7 %, and 22 %, respectively. CONCLUSION: Hard disk arrays are specifically suited as departmental intermediate storage media because they allow fast access to current and previous examinations within a short time. Performance properties enable both MOD and TAPE systems to serve as long-term archives. However, MOD archives are less flexible in the expansion of storage capacity and at present the medium costs per memory unit are about 2 - 3 times higher than for tape archives. The use of existing MOD-archives may be adequate as intermediate archives. For new PACS installations or system expansions, however, it is recommended to combine a sufficiently large local data memory (RAID) with data storage on tape archives outside the radiological unit that can be used by other departments as well. Future development of hard disk prices will show whether archiving for the whole data retention period may be handled by RAID systems. In any case, prefetching problems and waiting periods for demanded pre-studies would not occur any more.

[Improving productivity by implementing RIS and PACS throughout the clinic: a case study]. / Produktivitätsverbesserung durch klinikweite RIS und PACS: eine Fallstudie.

PROBLEM: How are improvements in productivity in connection with RIS/PACS to be defined? What do they cost? To limit the problem to the relevant topics, we first describe the objectives of a radiology department and the identified bottlenecks in the workflow. How to define and assess the improvements is discussed. METHODS: The case in question for this study is the RIS/PACS project at the "Klinikum der Universität München, Campus Grosshadern". The goals of the project and its present status are reviewed. The project is not yet completed, so this is a "midterm" report. RESULTS AND DISCUSSION: We describe the status of the achieved and not yet achieved goals and of the eliminated bottlenecks. On the plus side, for example, nearly 100% of all digitally generated images (except mammogramms) are digitally archived. They are accessible to the same percentage in radiology via PACS and in the hospital via the webbased intranet image distribution system when needed. In some radiology areas, such as multislice CT, already the reporting can no longer be performed without softcopy image interpretation. However, the full elimination of hardcopy images is still not reality, since the distribution to DICOM viewers for selected requesters with demands for almost reporting quality, high cost image displays is still in the testphase. To reduce film costs, images are being printed on a high resolution paper printer in addition to the intranet distribution during this transition period. On the negative side, due to a lack of job positions in the transcription rooms, about 40% of the reports are still being handwritten by radiologists. Furthermore, the dictated and transcribed reports are usually still not available early enough in the RIS and thereby in the intranet report distribution of the hospital. Here only a speech recognition system can remedy the situation. As soon as this problem is solved and the image distribution to the DICOM viewers works routinely, the reports and the images will be accessible within minutes to maximally within some hours after the examination. CONCLUSION: The goals reached so far suffered delays due to unforeseen problems and pitfalls. Altogether, a quieter operation and workflow in radiology has already been achieved, due to less inquiries from the requestors for unfinished examinations, images and/or image copies.

[Economic effects of integrated RIS-PACS solution in the university environment]. / Wirtschaftliche Effekte einer integrierten RIS-PACS-Lösung im universitären Umfeld.

PROBLEM: The goal of the current article is to demonstrate how qualitative and monetary effects resulting from an integrated RIS/PACS installation can be evaluated. METHODS: First of all, the system concept of a RIS/PACS solution for a university hospital is defined and described. Based on this example, a generic method for the evaluation of qualitative and monetary effects as well as associated risks is depicted and demonstrated. To this end, qualitative analyses, investment calculations and risk analysis are employed. RESULTS: The sample analysis of a RIS/PACS solution specially designed for a university hospital demonstrates positive qualitative and monetary effects of the system. Under ideal conditions the payoff time of the investments is reached after 4 years of an assumed 8 years effective life of the system. Furthermore, under conservative assumptions, the risk analysis shows a probability of 0% for realising a negative net present value at the end of the payoff time period. CONCLUSION: It should be pointed out that the positive result of this sample analysis will not necessarily apply to other clinics or hospitals. However, the same methods may be used for the individual evaluation of the qualitative and monetary effects of a RIS/PACS installation in any clinic.

[Uniform access to clinical data in a distributed system. The radiology example]. / Einheitlicher Zugriff auf klinische Daten in einem verteilten System. Beispiel Radiologie.

PURPOSE: Providing medical reports onwards and ambulatory settings in electronic form can improve the quality of health care delivery. Radiology was chosen as an example to demonstrate how to implement uniform access to clinical data in a hospital. METHOD: Medical professionals at the university hospital in Munich, Grosshadern, have access to all radiological reports of their patients. Web browsers are used as a front end. A centralized administration of users and patients is in place. RESULTS: Centralized access control and patient selection guarantee uniform access to all applicable data via intranet and controls access rights. The high acceptance of this service is reflected by the high number of 150 requests per day. DISCUSSION: Access to radiological reports within the Grosshadern University Clinics was enabled via web browsers in a short time. The high acceptance of the system also proves its easy use. Integration of the system in a centralized user and patient identification system supports the unified access to clinical data.

[Aspects of electronic patient records in radiology]. / Aspekte der elektronischen Krankenakte in der Radiologie.

PURPOSE: The computerized patient record must provide patient- and problem-oriented access to all relevant patient data for health care professionals. The aspects of such systems will be analyzed in the light of the radiologist's needs. METHODS: Integration of the computerized patient record in a hospital communication network allows automated data exchange with the ancillary systems. Accessibility of electronic textbooks supports case-based learning during routine work. RESULTS: The computerized patient record not only supports routine clinical tasks but also training, education and research. The workflow in a hospital can be supported by the computerized patient record. Studying the tasks of a radiology department shows that both clinicians and radiologists will benefit from such a system. DISCUSSION: Current implementations of clinical computerized workstations offer only a fraction of these features. Advances in technology and increasing demands at the point of care will promote the development of new information systems of this kind.

[Filmless documentation and image distribution to referring physicians exemplified by a radiologic community practice]. / Filmlose Befundung und Bildverteilung an Zuweiser am Beispiel einer radiologischen Gemeinschaftspraxis.

In healthcare, cost effectiveness as well as the quality of examinations and procedures are subjected to quickly increasing expectations and demands: we like to demonstrate how the resulting challenges and problems can be met with implementation of modern information technology. Analysing the respective demands (pattern of quantities) and choosing the adequate technical solution/technical approach, we found filmless reading and the usage of digital image distribution to communicate with referring physicians to be cost effective as well as of higher quality. Special attention should be paid to the rigorous maintenance of data security and access. Today's information technology allows individual adjustment to the respective size and requirements of a radiological department or practice for filmless reading and digital image distribution. Working with the systems as a matter of routine and using all of the expanding technological possibilities, an important improvement of service and quality can be achieved. Amortisation will be obtained despite high investments, due to the subsequent savings in personal- and enterprise costs.

Functional requirements for a HIS-RIS-PACS-interface design, including integration of "old" modalities.

Radiology, Information Systems (RIS) and Picture Archiving Systems (PACS), have the potential for immense rationalization of operations in radiology and hence for the improvement of health care, as well as the return of investments. These systems must, however, be carefully designed such that they support routine work rather than being an additional burden to radiology staff. Analyses show that comprehensive communication of patient demographic and clinical data between RIS, PACS and Hospital Information Systems (HIS) are necessary prerequisites to achieve cost effectiveness. Based on analyses of radiology operations in a large university primary care hospital, functional requirements and data structures for designing HIS/RIS/PACS interfaces are presented. These concern communication of past examinations, associated written reports and images, appointment scheduling, requests of new examinations, digitizing old analog X-ray films, access from RIS/PACS to other clinical data, and transfer of new radiology reports and relevant images. Consistency of all redundant data stored in the three systems is essential. A pragmatic, safe and inexpensive method of electronically integrating "old" modalities not fully "PACS capable" in the HIS/RIS/PACS world is presented.

[The filmless hospital--a legal challenge]. / Das filmlose Krankenhaus--eine juristische Herausforderung.

PURPOSE: This article concerns the legal aspects of digital archiving of radiological images, in particular with regard to the resolution passed by the 37th Committee meeting of the Federal Board of "RöV" (x-ray ordinance). Concepts of filmless hospitals must therefore be tested for compliance with all present legal requirements. MATERIAL AND METHODS: The literature concerning the legal aspects of digital medical archiving of x-ray documents is reviewed. The concept of a digital archive was compared with these aspects and tested for compliance with the respective legal rules. RESULTS: There are no legal obstacles to realizing our concept of a filmless hospital. However, there are no civil court rulings on record, since there have not been any legal proceedings to date. CONCLUSIONS: There are no legal objections to a complete digital archiving in a hospital in the absence of any court rulings to the contrary.

A computer-based reporting system in radiology of the chest.

The aim of this study was to compare our computer-aided report writing system to standard techniques. A computer-aided reporting system for reporting on chest X-rays was developed and linked with a UNIX-based radiology information system. The reporting system consists of different text modules which can be composed to a complete radiological report. The quality of the report, the system's efficiency, flexibility and availability at the radiology information system (RIS), as well as its acceptance by the users, were criteria we took as a basis of evaluation. Acceptance and flexibility of the system were tested by assessing necessary changes and additions performed to text modules and by subjective evaluation. The time spent on working with the reporting system was evaluated by performing a time-analysis study comparing the new system to the two conventional methods, the tape system and handwriting. On average, the readers needed 22.6 text modules for each report. For the users the most important advantages of the new system are that primarily fewer changes to or additions to the text are necessary, and when they cannot be avoided they can be performed more easily. In comparison with the tape system and handwritten reports, it took on average two and a half to three times longer to report on a chest X-ray. The printed report had left the department within 6.4 h using the tape system within 0.4 h when handwritten and within 1.4 h when recorded by the reporting system. The completeness of the set of modules and the logical order were positively assessed by the users. The demand of time for reporting increases, but the final report is available sooner.

[A report on experience with a second-generation PACS installation in routine computed tomographic operations]. / Erfahrungsbericht über eine PACS-Installation zweiter Generation im computertomographischen Routinebetrieb.

PURPOSE: Our institute has been using a pilot SIENET-PACS system for the last five years; its advantages and disadvantages in daily use are described. MATERIAL AND METHODS: The SIENET system connects 2 CT, 3 MRT and 2 angiographic installations with 7 viewing consoles and with an optical archive. From January 1994 to 1997 approximately 19,000 patients were examined by CT and the results stored digitally in the PACS system. RESULTS: A representative analysis of selected patient data revealed problems in 12.8% of patients with regard to the radiological information system and also the hospital information system. While the digital data proved satisfactory, the production of digital images was excellent but time-consuming. The image archive was reliable but required greater capacity for our purposes. CONCLUSIONS: Manual retrieval of patient data presented problems and integration of the radiology information system and PADS is essential. Digital data gathering is an advantage. Digital imaging is too slow and should be improved by more suitable software. Integration of new archival storage methods and compatibility with the DICOM standard is, judging form our experience, essential.

The full-scale PACS archive. A prerequisite for the filmless hospital.

PURPOSE: Increasing percentages of digital modalities in radiology, in particular of digital image acquisition in conventional radiography, call for digital reporting, communication, and archiving techniques. These techniques are prerequisites for the "filmless" hospital. The first 2 have been covered extensively in the literature and by vendors. However, as regards online digital image archives there are still no satisfactory concepts available in the medical field. The present paper puts forward some suggestions as to how this situation could be improved. MATERIAL AND METHODS: Analyses of radiology operations consider the prevailing PACS (picture archiving and communication system) archive concepts that use optical discs to be too small, too slow and too cumbersome to manage and therefore unable to function as comprehensive image archives for filmless hospitals. We suggest borrowing and adapting the well tested archive technologies from space research and the oil and broadcasting industries which have much higher capacities and speeds and better software interfacing possibilities. With such technologies the needs of filmless hospital operations can be met. RESULTS: A feasible concept for a transition strategy from conventional analog to digital archives is presented. Model calculations of the necessary investments and potential savings, including generous placement of viewing stations in the entire hospital, indicate amortization periods of 3.8-4.8 years. CONCLUSION: Alternative technologies for digital image archives already today make full-scale PACS for filmless hospitals technologically and conceptually feasible and financially mandatory.

[Digital radiography. Cost-benefit analysis]. / Digitale Radiographie. Kosten-Nutzenanalyse.

Due to its high dynamic range and contrast discernibility, digital radiography offers substantial advantages compared with conventional film-screen systems. Moreover, further advantages can be assumed for radiation protection. Digital radiography also allows conventional image data to be included in PACS (Picture Archiving Communication System). These well-known advantages are faced with legal questions which are not yet settled. Cost effectiveness in using systems of digital radiography and PACS are also under discussion. By means of examining economic efficiency and cost analysis of digital radiography systems, economic effectiveness was assessed. This was also compared with conventional alternatives. As a result, it may be assumed that amortization is reached in three to four years. Based on lower costs for films, digital systems are more cost effective than conventional systems after this period.