Reporting Whitepaper - Section 6.3

<Return to the main Reporting Whitepaper page>

<Lets try to separate the "abstract" workflow (steps to be performed, outputs and inputs) from the technical infrastructure (T1, routers, which RIS holds order)>

<Note that "legal requirements" will likely result in multiple branches in the workflow or alternate workflows, e.g. night scans outputs are put on hold until formally reviewed by a staff radiologist in the morning. Should try to abstract the basic requirement of "hold for overread" that can apply to a variety of situations.>

6.3 Reading Service

Currently Radiology Practices in the United States outsource the after hour Reading (primarily Emergency) to independent Radiology Reading Companies. These independent Service Companies employ US Board Certified Radiologists to read Radiological Procedures and report the findings directly to the Hospital or Imaging Centers.

<Need Author/Input>

<Chris will see if we can get input from Dr. Keith Dryer – Mass General, Dr. David Mendelsson – Institution perspective on Reading Services>

6.3.1 Service Provider Viewpoint 1

Jeff Davies, VP of Sales for Franklin & Seidelmann Subspecialty Radiology (F&S), a national subspecialty teleradiology interpretation provider in the U.S. (http://www.franklin-seidelmann.com/) took the time to document a relatively generic teleradiology reporting workflow. He is available for further discussion if needed:

<Issues when bringing in a new “client” each time>

<Issues of managing all the separate clients in one workflow>

<Different reading services may vary significantly in their workflows / architectures>

<Some will have a “distributed workforce” who may even be working out of their homes, others will look like an imaging center with no modalities>

<Technologies include integrated “normal” systems, and also “web-based” clients which in some cases may have reduced resolution/fidelity>

<Another issue is that they are often used to cover “night hours” so the workflow at the client institution needs to shift seamlessly from internal reading to external reading and back again, In theory, clients will over-read a percentage of the service reads as a quality control measure>

<Hard to imagine this involving film, which also means that often priors are not included in the read. Sometimes the client will supply priors as part of the study.>

To scale effectively and therefore to make money, any telerad business must have the radiologists sign into 1 system (the telerad’s “RIS,” whatever that means) vs. logging into the client’s systems. This inherently and automatically creates workflow issues. I will discuss the telerad component/telerad workloop but obviously there is a lot of work that goes into the pre and post telerad workloop for an imaging entity (imaging center, hospital, orthopedic practice, etc.) that is using the telerad service.

Imaging Facility tech scans patient and sends the study to their internal “PACS” and simultaneously via a VPN tunnel, to “Trad” (fictitious name of telerad vendor). Imaging Facility tech, or someone else at the imaging facility (IF) front desk, fills out Trad “order form” and faxes that over to Trad.

Trad receives the “order” and manually enters that “order” into Trad RIS. In our case, the order is sent to Trad routing cops known as Air Traffic Control. ATC is also the department that receives study images from IF and deposits them into the Trad PACS (ultimately this could and should be automated but today is too tricky so needs to be done manually).

ATC matches the study images to the order and then assigns and forwards that study to the right radiologists who has the respective subspecialty and who is licensed in that state.

<Routing considers worker Load balancing, client quality-of-service/turnaround time agreements, state licensing, and specialty knowledge/certification requirements>

Trad Radiologist receives the study in their RIS worklist and pulls up the matching images in the viewer (in this case eFilm).

Tradiologist picks up Dictation System and dictates the name, DOB, SSN and order and begins dictating the study.

Transcription listens to the dictation in the dictation systems and sorts through the Trad RIS worklist to find the respective study and then transcribes/types back into Trad RIS.

Once transcription is complete the study is routed back to the Tradiologists who electronically “signs” the report in Trad RIS triggering autofax or, in our case, the posting of that final report to a website from which IF can pull the reports. Signing the report also triggers an e-mail providing indication to the IF that the report is ready.

Notes: After the report is sent back to IF either by fax or FTP (perhaps text, Word or a PDF), IF must then find a way to get that report back into their internal RIS (assuming that is their requirement). This could potentially occur via HL 7 but see below.

<Workflow needs to differentiate between the service read as a preliminary report and then the client does their “normal” process to finalize the report. This fits well with the service as an “emergency” method of doing wet-reads>

<Issues also arise in terms of client preferred formats or templates.>

<Might be interesting to look at communicating site policies as well>

This workflow scenario is quite different from another Trad vendor who may be only providing preliminary results for after hours coverage or from another Trad which does not subspecialize eliminating the necessity for ATC routing decisions. In the preliminary read example, only a wet read is faxed over to IF and then the radiologist who covers the facility over reads and provides the final radiology report the next day. (In our view of the world, we categorize ourselves as a subspecialty radiology group that uses tele to deliver our product vs. a teleradiology company who provides commodity coverage.)

The advantage is a report/service that IF isn’t able to get otherwise.

The disadvantage is the “broken” workflow. As Trad is an “outside” entity from the IF and has many clients the workflow by nature can not be as “integrated” as in-house workflow can be. As soon as one IF client workflow is different from another IF client, it requires that Trad workflow be ubiquitous and therefore perhaps “dumbed down.” HL 7 Interfaces can and do exist but are complex and costly.

If automated inter company workflow via HL 7 were to occur, Trad would need a very robust and sophisticated HL 7 engine that accounts for 165 unique interfaces. Furthermore, if you start talking about DICOM Modality Worklist and other sophisticated workflow integrations, things even get more complex.

6.3.2 Service Provider Viewpoint 2 - NightShift

Radiology Reading Services are often hired to cover the after hour needs of Hospitals. These Radiology Reading Services have their own internal RIS/PACS Sysems and typically connect to the Hospitals through specialized networks (e.g. T1) to transfer images, email and fax services.

Contractually both the Radiology Service and the Hospital contract with the Radiology Practice. The Radiology Practice is therefore responsible for the final readings in all cases (and billing to the Patient).

The Radiology Service Companies control the reading workflow independently of the Hospitals. Typically a single Radiologist will handle cases from multiple Hospitals from multiple States (each of which they must be Board Certified). In the case of NightShift the Radiologists are assigned Hospitals for the shift (16 is a typical number), and they are expected to manage the workload. The Radiologists are expected to handle all types Radiology Procedures with the exception of Mammography. Mammography is typically not handled by Radiology Reading Services for several reasons including: on-going certification requirements, the need for priors, the size of the studies. All of the Radiologists on duty have access to all of the Images, so in cases where one of the Radiologists needs help, they have access to the required information.

The readings done by the Radiology Service start at a fixed time. Once the shift begins, a router is set so that Images for each Study are transferred to the Radiology Reading Services System a well as the local System. Since Productivity is so critical to the success of the Radiology Reading Services Productivity meters are built into the system. Once all the images have been transferred to the NightShift PACS, the study is placed in the Radiologist's Reading Worklist and marked "green". If the Study has not been started within 20 minutes it is marked "yellow" after 30 minutes the case is marked "red". The Radiology Reading Services System keeps track of the following statistics which are reported back to the Radiology Practice:

• • Number of Cases handled per hour
  • Number of Cases handled per night
  • Number of Cases handled in the first 10 minutes
  • Number of Cases handled in the first 30 minutes
  • Number of Cases taking over 1 hour

Besides the Images, the Radiologist cannot start Reading a study until they receive the Worksheet (faxed) which provides the Radiologist with all of the information they will have about the case. This includes:

• • Prior Reports
  • Number of Prior Images available
  • Total Number of Images Sent (Required legally, but sometimes it is still missing).

It is important to understand what the Radiologist does not have as a part of performing the Read:

• • Limited Patient History. Only information provided on the Worksheet filled out by the Technologist, ER Doctor or other Attending Physicians.
  • Limited Order information. There is no RIS connection, so the only Order information is the information provided on the Worksheet.
  • Typically no Allergy, Medication, etc. information.
  • Patient Age frequently not available.
  • Few Priors. In a typical evening, a Radiologist will get 5-6 Priors out of 140 Cases. (This may be a technology limitation. It takes a lot of time to send priors over a T1)

In the case of Nuclear Medicine cases it is not atypically to not receive the required Chest X-Ray images (current within 24 hours) which needed to properly read.

A Read can start once the Radiologist has received all of the paperwork and the images. At this point the Review Status will indicate the following information:

• • Patient Name
  • Study Date/Time
  • Received Data/Time

Some of the issues with not being able to start the Read include:

• • The Radiology Reading Service System doesn't know about the Worksheet, so a Study may be set to ready to read even if the Worksheet has not been faxed. It is up to the Radiologist to track the worksheet down. Typically this entails calling the Hospital.
  • Sometimes the Hospital has completed the Radiological Procedure (and/or Worksheets), but hasn't sent the items. They are then waiting on results which the Radiology Service Radiologist doesn't know about.
  • Some CT Equipment is so fast that the Patient is done and the images have still not been received by the Radiology Service systems.

Once a Radiologist starts a case, their Reading Environment is similar to an in-house Radiologist. The Radiology Services typically configuration is a dual reading monitor for images, a monitor for the Reading Worklist, and a monitor for the Report. Reports are created using a dictation system. Radiologists only have access to the Priors in the Radiology Service Archives. This includes Priors that have been sent with the current read, and potentially priors read by the Radiology Service within the last day or so.

30-40% of the cases are ER Cases. The other percentage is split between the Outpatient Procedures and Inpatient Procedures. Typically the work for the Outpatient Procedures start at 5:00 AM and includes procedures required to complete the Outpatient Visit for the day. Frequently during the Reading the Radiologist will need to speak with the Attending Physicians. A phone list for the Hospital - Technologists, ER Doctors, etc. is available on the Radiology Services System. In addition, the Worksheet may provide additional phone numbers for Attending Physicians. In the case of ER Cases, the Radiologist will normally talk to the Attending ER Physician. In the case of Outpatient Procedures the Radiologist will use the Technologist to located the Physician. In all other cases the Radiologist needs to use the Paging System provided by the Attending Physician. Significant time may be spent locating a Physician. Additionally a significant amount of phone time may be necessary to complete the case.

When the Radiologist is done with the Report, it is sent out as a Preliminary Report, as only the Radiology Practice can provide the final report. At this time NightShift does not use any common report formats. It is up to the individual Radiologists. The Radiology Service System has a list of places to send the reports. This includes:

• • ER Fax Numbers
  • ER Fast Send (via email)
  • Inpatient - Hospital List of Fax Numbers by Floor/Area
  • Radiology Fax Numbers

The Radiology Department always receives a copy of the report. New fax numbers/email addresses can be added to the system on a temporary or permanent basis. The Preliminaty Reports are tyically used by the Hospital; however, the final Report must be submitted by the local Radiology Practice. At this point almost all of the reports are re-dicated by the local Radiology Departments. Only one Hospital out of all the systems supported by NightShift accepts the Preliminary Report submitted by NightShift (don't know the technology).

After the local Radiology Practice finalizes the report, the last step is to document any descrepancies between the Radiology Service Results and the local Radiology Practice. Descrepencies must be responded to and they are rated. These statistics are kept and are provided to the Radiology Practice as part of the monthly Productivity reporting.

<Day Read Services and MRI Service for a Fee are different types of Radiology Services which also exist.>

<Lots of ER studies (don't generally schedule for night scans), some "load balancing" for the hospital, perhaps some vacation coverage>

<Apparently some contractual limitations placed by the staff radiologists limiting their ability to do the reads in the day.>

<Is there any specialty coverage? In such cases there wouldn't be an "overread" at requestor>

<Might want to have a different subsection for cases where Reading Service is as a second opinion, or where the reading service is really a large hospital in a big city providing specialty reads for a hospital in a smaller town>

<Need support for recording/communicating discrepancies. Some services/rads are rated based on their discrepancy rate.>

<Technical Q: Who is recorded in the report as the Radiologist of Record. Does the other appear? etc. Probably should follows the practice for residents, but currently the integration is so poor that information gets lost.>