Impact of PACS-EMR Integration on Radiologist Usage of the EMR.

The purpose of this study was to objectively quantify the impact of implementing picture archiving and communication system-electronic medical record (PACS-EMR) integration on the time required to access data in the EMR and the frequency with which data are accessed by radiologists. Time to access a clinic note in the EMR was measured before and after integration with a stopwatch and compared by t test. An IRB-approved, HIPAA-compliant retrospective review of EMR access data from security audit logs was conducted for a 14-month period spanning the integration. Correlation of these data with report signatures identified the studies in which the radiologist accessed the EMR to obtain additional clinical data. Proportions of studies with EMR access were plotted and compared before and after integration using a chi-square test. Time to access the EMR decreased from 52 to 6 s (p < 0.001). Proportion of studies with EMR access increased from 36.7% (10,175/27,773) to 44.9% (10,843/24,153) after integration (p < 0.001). Integrating PACS and the EMR substantially decreases the time to access the EMR and is associated with a significant increase in the proportion of studies for which radiologists obtain additional clinical data.

Correlate: A PACS- and EHR-integrated Tool Leveraging Natural Language Processing to Provide Automated Clinical Follow-up.

A major challenge for radiologists is obtaining meaningful clinical follow-up information for even a small percentage of cases encountered and dictated. Traditional methods, such as keeping medical record number follow-up lists, discussing cases with rounding clinical teams, and discussing cases at tumor boards, are effective at keeping radiologists informed of clinical outcomes but are time intensive and provide follow-up for a small subset of cases. To this end, the authors developed a picture archiving and communication system-accessible electronic health record (EHR)-integrated program called Correlate, which allows the user to easily enter free-text search queries regarding desired clinical follow-up information, with minimal interruption to the workflow. The program uses natural language processing (NLP) to process the query and parse relevant future clinical data from the EHR. Results are ordered in terms of clinical relevance, and the user is e-mailed a link to results when these are available for viewing. A customizable personal database of queries and results is also maintained for convenient future access. Correlate aids radiologists in efficiently obtaining useful clinical follow-up information that can improve patient care, help keep radiologists integrated with other specialties and referring physicians, and provide valuable experiential learning. The authors briefly review the history of automated clinical follow-up tools and discuss the design and function of the Correlate program, which uses NLP to perform intelligent prospective searches of the EHR. © RSNA, 2017.

Patient Radiation Dose Reduction during Transarterial Chemoembolization Using a Novel X-Ray Imaging Platform.

PURPOSE: To evaluate radiation dose reduction in patients undergoing transarterial chemoembolization with the use of a new image acquisition and processing platform. MATERIALS AND METHODS: Radiation-dose data were obtained from 176 consecutive chemoembolization procedures in 135 patients performed in a single angiography suite. From January 2013 through October 2013, 85 procedures were performed by using our institution's standard fluoroscopic settings. After upgrading the x-ray fluoroscopy system with an image acquisition and processing platform designed to reduce image noise and reduce skin entrance dose, 91 chemoembolization procedures were performed from November 2013 through December 2014. Cumulative dose-area product (CDAP), cumulative air kerma (CAK), and total fluoroscopy time were recorded for each procedure. Image quality was assessed by three interventional radiologists blinded to the x-ray acquisition platform used. RESULTS: Patient radiation dose indicators were significantly lower for chemoembolization procedures performed with the novel imaging platform. Mean CDAP decreased from 3,033.2 dGy·cm(2) (range, 600.3-9,404.1 dGy·cm(2)) to 1,640.1 dGy·cm(2) (range, 278.6-6,779.9 dGy·cm(2); 45.9% reduction; P < .00001). Mean CAK decreased from 1,445.4 mGy (range, 303.6-5,233.7 mGy) to 971.7 mGy (range, 144.2-3,512.0 mGy; 32.8% reduction; P < .0001). A 20.3% increase in mean total fluoroscopy time was noted after upgrading the imaging platform, but blinded analysis of the image quality revealed no significant degradation. CONCLUSIONS: Although a small increase in fluoroscopy time was observed, a significant reduction in patient radiation dose was achieved by using the optimized imaging platform, without image quality degradation.

Providing formal reports for outside imaging and the rate of repeat imaging.

OBJECTIVE: The purpose of this study is to assess whether providing a formal report for outside imaging reduces repeat imaging. MATERIALS AND METHODS: From January 1, 2006, through December 31, 2011, patients transferred with an abdominal CT from another ("outside") institution that was imported to our institution's PACS within 60 days of the original CT were considered. Repeat imaging was defined as when an abdominal CT performed at another institution was followed by the same study at our institution in the 14 days after import to PACS. The rate of repeat imaging was compared between patients whose outside imaging did and did not receive a formal report from our radiologists. RESULTS: Consecutive patients (n = 10,330) who imported an outside abdominal CT to our PACS were considered. Thirty-six percent (3719/10,330) received a formal report. These patients were 32% less likely than the other patients to undergo repeat imaging (9.4% [350/3719] vs 14% [919/6611]; p < 0.001). The odds of repeat imaging were statistically significantly lower for patients who received a formal report after adjusting for potential confounding variables, including the age of the outside imaging study and the referring specialty (multivariate odds ratio, 0.53; 95% CI, 0.47-0.61; p < 0.001). CONCLUSION: Patients who received a formal report for their outside abdominal CT examinations were less likely to have repeat imaging. Institutions, payers, and policy makers should consider providing and supporting formal reports for outside imaging.

Reducing the rate of repeat imaging: import of outside images to PACS.

OBJECTIVE: Repeat imaging at the transfer of care between institutions is a potential source of overutilization. The purpose of this study was to assess whether importing images obtained at one institution to the PACS at another institution reduces the number of repeat imaging examinations performed, sparing patients unnecessary cost and radiation. MATERIALS AND METHODS: Informed consent was waived for this retrospective study, which included 267 patients who had undergone CT or MRI of the abdomen at our or another institution within 4 months before transarterial chemoembolization. Patients were divided into the following four groups based on the availability of their images from institutions other than ours (outside images): outside imaging performed but images not available; outside images available on CD or film but not imported; outside images imported to PACS; and no outside imaging, that is, all imaging performed at our institution. The rates of repeat imaging in the four groups were compared. RESULTS: When outside images were not available, 72% (13/18) of patients underwent repeat imaging; when outside images were available but not imported, 52% (14/27); when outside images were imported to PACS, 11% (9/79); and when imaging was performed only at our institution, 13% (18/143). Patients whose outside images were imported were significantly less likely to undergo repeat imaging than were both groups whose outside images were not imported (p < 0.001), and their rate of repeat imaging was similar to that of patients who did not undergo outside imaging (p = 0.79). After adjustment for potential confounders, including age, sex, referring institution, and size and number of lesions, the odds that a patient whose images were imported would undergo repeat imaging were significantly lower than those of a patient whose outside images were not imported (odds ratios, 31 for images not available and 9.0 for images available but not imported; both p < 0.001) and were similar to those of a patient who underwent all imaging at our institution (odds ratio, 0.71; p = 0.51). CONCLUSION: Importing outside images to PACS reduces the rate of repeat imaging.

Using Java to generate globally unique identifiers for DICOM objects.

Digital imaging and communication in medicine (DICOM) specifies that all DICOM objects have globally unique identifiers (UIDs). Creating these UIDs can be a difficult task due to the variety of techniques in use and the requirement to ensure global uniqueness. We present a simple technique of combining a root organization identifier, assigned descriptive identifiers, and JAVA generated unique identifiers to construct DICOM compliant UIDs.

Informatics in radiology: IHE teaching file and clinical trial export integration profile: functional examples.

The digital revolution in radiology introduced the need for electronic export of medical images. However, the current export process is complicated and time consuming. In response to this continued difficulty, the Integrating the Healthcare Enterprise (IHE) initiative published the Teaching File and Clinical Trial Export (TCE) integration profile. The IHE TCE profile describes a method for using existing standards to simplify the export of key medical images for education, research, and publication. This article reviews the authors' experience in implementing the TCE profile in the following three processes: (a) the retrieval of images for a typical teaching file application within a TCE-compliant picture archiving and communication system (PACS); (b) the export of images, independent of TCE compliance of the PACS, to a typical teaching file application; and (c) the TCE-compliant transfer of images for publication. These examples demonstrate methods with which the TCE profile can be implemented to ease the burden of collecting key medical images from the PACS.

Using applet-servlet communication for optimizing window, level and crop for DICOM to JPEG conversion.

In the creation of interesting radiological cases in a digital teaching file, it is necessary to adjust the window and level settings of an image to effectively display the educational focus. The web-based applet described in this paper presents an effective solution for real-time window and level adjustments without leaving the picture archiving and communications system workstation. Optimized images are created, as user-defined parameters are passed between the applet and a servlet on the Health Insurance Portability and Accountability Act-compliant teaching file server.

Translating the IHE Teaching File and Clinical Trial Export (TCE) profile document templates into functional DICOM structured report objects.

The Integrating the Healthcare Enterprise (IHE) Teaching File and Clinical Trial Export (TCE) integration profile describes a standard workflow for exporting key images from an image manager/archive to a teaching file, clinical trial, or electronic publication application. Two specific digital imaging and communication in medicine (DICOM) structured reports (SR) reference the key images and contain associated case information. This paper presents step-by-step instructions for translating the TCE document templates into functional and complete DICOM SR objects. Others will benefit from these instructions in developing TCE compliant applications.

The Economic and Social Value of an Image Exchange Network: A Case for the Cloud.

As the health care environment continually changes, radiologists look to the ACR's Imaging 3.0® initiative to guide the search for value. By leveraging new technology, a cloud-based image exchange network could provide secure universal access to prior images, which were previously siloed, to facilitate accurate interpretation, improved outcomes, and reduced costs. The breast imaging department represents a viable starting point given the robust data supporting the benefit of access to prior imaging studies, existing infrastructure for image sharing, and the current workflow reliance on prior images. This concept is scalable not only to the remainder of the radiology department but also to the broader medical record.

Informatics in radiology (infoRAD): Vendor-neutral case input into a server-based digital teaching file system.

Although digital teaching files are important to radiology education, there are no current satisfactory solutions for export of Digital Imaging and Communications in Medicine (DICOM) images from picture archiving and communication systems (PACS) in desktop publishing format. A vendor-neutral digital teaching file, the Radiology Interesting Case Server (RadICS), offers an efficient tool for harvesting interesting cases from PACS without requiring modifications of the PACS configurations. Radiologists push imaging studies from PACS to RadICS via the standard DICOM Send process, and the RadICS server automatically converts the DICOM images into the Joint Photographic Experts Group format, a common desktop publishing format. They can then select key images and create an interesting case series at the PACS workstation. RadICS was tested successfully against multiple unmodified commercial PACS. Using RadICS, radiologists are able to harvest and author interesting cases at the point of clinical interpretation with minimal disruption in clinical work flow.

Development of a dedicated hepatopancreaticobiliary program in a university hospital system.

In 2001, a dedicated hepatopancreatobiliary (HPB) cancer program was established at a large, university hospital. Changes included recruitment of specialized HPB faculty, standardization of patient protocols, development of coordinated multidisciplinary research and clinical efforts, collection of prospective surgical outcomes data, and construction of a dedicated cancer hospital. The aim of this study was to evaluate the impact of this program on a university health system including effects on patient volume, surgical volume, outcomes, costs, resident education, and research productivity. Hospital and departmental databases were reviewed for all records pertaining to HPB surgical cases, diagnosis, and financial information over a 6-year period, including 2 years before (1999-2000) and 4 years after (2001-2004) HPB program development. A more than two-fold increase in the number of distinct patients who had HPB diagnosis was seen across all pertinent departments. A five-fold increase in surgical volume was observed. A multidisciplinary approach to care was implemented, leading to a four-fold increase in sharing of patients across departments. Improvements in operative mortality, hospital contribution margin, resident operative experience, and research productivity were observed. The implementation of a dedicated HPB cancer program with coordinated and standardized research, educational, and clinical efforts had measurable institutional benefit.

Beyond PACS: getting images to referring physicians.

The digital imaging hospital has the potential advantage that imaging studies are available anytime, and anywhere they are needed, with negligible loss. Fulfilling this promise in reality, however, presents challenges as described in this paper. No single best formula for successful deployment exists, since each institution is unique, and its medical staff may have varying preferences. This requires a collaborative team approach to design a solution acceptable to all parties, inside and outside of radiology. We have attempted to identify the significant issues. In addition, hardware and software technology continuously evolve and improve. What is clear is that all institutions will adopt this technology for the reasons described. The successful implementations will be those that are collaboratively and thoughtfully designed. User training of all members of the healthcare team involved with image study access is essential.