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Steven Horii, MD, FACR, FSIIM. Professor of Radiology, . Clinical Director , Medical . Informatics Group. Modality Chief, Ultrasound. Hospital . of the . University . of . Pennsylvania. Attending Radiologist, Children’s Hospital of Philadelphia. ID: 568918

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Practical guide: Medical Imaging Concepts

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Practical guide: Medical Imaging Concepts
Steven Horii, MD, FACR, FSIIM
Professor of Radiology,
Clinical Director , Medical Informatics Group Modality Chief, Ultrasound Hospital of the University of Pennsylvania Attending Radiologist, Children’s Hospital of Philadelphia
Clinical and workflow
Disclosures
My wife is a full-time employee of
Cerner Corporation
Site PI, Phase III clinical trial, ultrasound contrast for liver masses,
Bracco
Pharmaceuticals, Inc.
Expert witness, Blakely
Sokoloff
Taylor &
Zafman
, LLP (Patent litigation)
Introduction
A tiny bit
about clinical stuff
The unavoidability of workflow
The complexity of workflow and multiplication of that through interacting
(or colliding) workflows
The changing healthcare model
What that means for you
Clinical
What we do
What do you mean “we”,
kemosabe
?
OK, then – what do physicians in general do; with some radiology particulars
Workflow
How
we do it
In twenty minutes?
OK, then –
Why workflow
can
seem
simple
Why it generally is not
Why is workflow important?
Clinical: An overview
Physicians:
Given a story or complaint by a patient,
Try to figure out what, if anything, is wrong
Figure out a treatment plan
Treat the patient
If the patient is not improving, return to bullet item 2
Oh
yeah, get paid
Clinical: An overview
Notice anything?
From a description of what we do, a flow diagram (of sorts) comes out
It is difficult to separate what we do from how we do it
What do radiologists do?
Image humans (and animals) to:
Diagnose diseases or anomalies
Guide and perform
procedures
Help develop treatment plans
Evaluate progression or regression of
disease (response
to
treatment)
Assist in forensic investigations
0
Imaging
Mechanical
energy (ultrasound)
Electromagnetic energy
RF (MR imaging)
Infrared (thermal)
Visible light (endoscopy, ophthalmology, dermatology)
Ultraviolet (fluorescence microscopy)
Gamma (radiographic imaging)
Protons (radiation therapy)
1
Adult liver
A 50 year old man with cirrhosis and worsening LFTs
2
Adult liver: good news for this patient
This is color flow and power Doppler: it shows that the blood
vessels in the liver are not distorted by any “mass”.
3
Obstetrical ultrasound
4
How we do it: Workflow
I recommend review of the IHE Profiles
for radiology if you are not already familiar with them
The profiles were developed largely through detailed examination of radiology workflow
5
Scheduled Workflow Profile
Registration
Orders Placed
Orders Filled
Film
Film
Folder
Image Manager
& Archive
Film
Lightbox
report
Report
Repository
Diagnostic
Workstation
Modality
acquisition
in-progress
acquisition
completed
acquisition
completed
images
printed
Acquisition
Modality
6
Why are healthcare workflows so complex?
Legacy procedures
and systems
We are idiosyncratic (Paul Chang)
Interactions between departments
Many personnel, each with particular tasks to perform and information needed
7
Complex workflow: intraoperative ultrasound
We provide ultrasound
in the operating room to assist the surgeons in locating structures and planning surgical approaches
About 20% of the time, the ultrasound changes the surgical plan
8
Display during intraoperative scanning
With permisson: Susan Rowling, MD, Frank Spitz, MD
9
Display: the radiologist’s view
0
Intraoperative ultrasound example
A 41 year-old woman with colon carcinoma for resection ofa solitary liver mass
1
The mass looks more like normal liver after compression
This is NOT another metastasis – it is an
hemangioma
;
a benign liver lesion.
2
Intraoperative ultrasound
Often resulted in delays for both surgery and radiology
Surgeons
had to wait for 20 minutes or more for us to arrive with our equipment
For radiology, it added to patient waiting time (took a radiologist and sonographer out of the Department)
3
Basic workflow: Intraoperative liver
4
Delays
We noted that some intraoperative
ultrasound studies were subject to much greater delays than others
We thought that one difference was whether or not the study was scheduled in advance
We looked at the difference in workflow
5
The non-scheduled workflow addition
6
The non-scheduled workflow addition
Included more steps
Each step involved
time
Once we showed how many more steps were involved, we discussed this with the surgeons and explained that scheduling ahead of time would result in shorter delays
They now routinely schedule their studies
7
Intraoperative ultrasound
Illustrates that an already complex workflow
in radiology,
Is made more complex when it involves interaction with another department’s workflow
Note that this does not even include the workflow steps done by surgery
8
Intraoperative ultrasound
Also
shows the need for standardization in the OR (hence the DICOM in Surgery WG)
There are vendor-based standards, but they are usually proprietary
There are standards (HDMI for video) that permit display on different devices, but not integration/interoperation
9
Why is this stuff important for you?
Much of radiology workflow grew out of the film, paper, and pencil age
This includes not only processes, but organization
Radiology had been largely radiology-centric
This in a time when “patient centered” has become a goal
0
Opportunities
Our workflow tends to be supported by thick
client, customized software
It is neither agile nor adaptable
The rapid changes in healthcare have meant much more difficult transitions for our legacy information systems
1
Big changes are coming
Remember the bit about “getting paid”?
Much
of our (meaning healthcare in general) workflow is based on a fee for service model
The service-oriented specialties (radiology and pathology in particular) are effectively piece workers
2
The approach to reducing healthcare costs
The US Government has, in
response to escalating healthcare costs, attempted to fix this by reducing payments to hospitals and physicians
What is the logical response to reduced reimbursement per procedure?
Why, perform more procedures, of course!
3
The newer model for reimbursement
Accountable care
Reimbursement
is based on outcomes, cost reductions, and appropriateness rather than just what was done
How can radiology prepare for this?
It is why you are (or should be) hearing about quality measures, appropriateness criteria, and meaningful use
4
Examples
CPOE – show that use improves
appropriate requesting of imaging studies
ACR Imaging 3.0
The Leapfrog Group
-
founded by large purchasers of healthcare services, mostly large
corporations
5
Importance for you (us)
We need to be agile and adaptable enough to provide
the informatics and information technology resources to support changes in the way healthcare is practiced and reimbursed
6
The emphasis
The emphasis will be (and is) on:
Rapid data mining
Increased patient involvement
Improved
communication between healthcare providers
Demonstrating improvements in outcome
Proving increased efficiency
7
Think about how these things can be accomplished
Do
you want to continue to write monolithic thick client applications with numerous customizations?
And then have to debug, support, and update them?
This meeting gives me hope that there is a better way and you folks are practicing it