Use Case Workflow and Error Reconciliation

Mammo Acquisition Workflow and Errors Reconciliation

Below are some error scenarios that are up for consideration:

1. How universal or significant is this problem?
2. Existing mechanisms within SWF, DICOM, or other guidance to reconcile the error?
3. What are really integration issues and what are just good product design issues?

Worklist and other demographic errors - Use Cases

1. Single patient worklist selection error:
   • Technologist selects the wrong worklist item from the list (item schedule for patient A, but performed on patient B).
   • Technolgist completes the patient examination, then realizes that the patient was done under the wrong patient and study identifiers.
   • Technologist does not have the proper clearance to correct her mistake at PACS, and the PACS admin doesn’t believe that he can correct or delete the study in PACS, whose images are now attributed to the wrong patient (patient A).
   • The healthcare facility would like to remove the mammography record permanently from the record of the wrong patient (patient A).
   • The facility would like to not re-expose patient B to get properly labeled images in records (also do not want to ask a patient to return, as well).
   • The technologist would like to re-assign her already acquired images to the correct worklist item for patient B.
   • The radiologist would like an indication at the workstation that the images of patient B really do not belong to patient A as labeled so that any misdiagnosis and mis-reporting of patient A is avoided.
   • The radiologist would like to see patient B’s images labeled with patient B’s correct information, including correct order information.
   • The facility would like a clean order for patient A (either use the original with confidence that it won’t be a problem, or cancel the original and generate a new, clean order). They do not want to add images to the already tainted study UID and accession number. They want all related integrated systems (scheduling, billing, reporting, etc.) to be properly reconciled with the original order and changes to the order.
   • The radiologist also wants the CAD objects associated with the corrections to be placed on the proper patient.
   • The radiologist also wants to make sure that prior exam comparison images are associated with the proper patient.
   • Any export or retrieval of patient records should contain only the images attributed to the patient whose records are being exported
2. Multiple patient worklist selection error:
   • Technologist selects the wrong worklist item from the list (item schedule for patient A, but performed on patient B).
   • During patient B’s exam, in another room, a technologist with patient A selects the same, correct worklist item for patient A. [Note – a comment from one technologist is that she wished the “system” could lock out the other system from selecting a worklist item that was already in use]
   • Both patient B’s and patient A’s images are mixed within the same patient and study identifiers
   • The technologist who made the mistake wants to correct her mistake and label patient B’s images properly.
   • The study can not be deleted out of PACS because it contains not only improperly labeled images (patient B), but properly labeled images (patient A).
   • The facility does not want to re-expose either patient for the sake of proper labeling.
   • The radiologist wants to see patient A’s images (and priors and CAD), but not see patient B’s images when making a diagnosis for patient A.
   • The radiologist wants to see patient B’s images with the associated CAD and prior exam images for patient B, and not see any references (labeling, objects) associated with patient A.
   • Everyone would like to not confuse patient B’s and patient A’s images ever in the future (need to reconcile archived records for retrieval and export). Note: the technologist suggested a way to split up accidentally merged patient records would be a help.
3. Procedure order error
   • A patient has a standard screening exam ordered, but she has implants.
   • The tech is told to adjust the order at the RIS, but doesn’t have access to this system.
   • The tech does the standard screening, then adds another procedure to acquire the implant views, resulting in two studies (or two procedure steps of the same study)
   • The tech (or someone else) has to go to the RIS to adjust the charges for the exams performed vs. those ordered.
   • Note: the tech relaying the issue wished for an easy procedure conversion at the modality that would switch the order from the standard screening to an implant screening exam. I’m guessing that this is just an application of the append/change order case with upstream and downstream systems adjusting without manual intervention.
4. Demographic errors I
   • During an exam, the patient and technologist discover that identifying patient information supplied by the worklist is not correct (like MRN when SS# are used, last names).
   • The technologist does not have access to the registration system to fix the demographic errors, but does not want to acquire images (or has already acquired images) that have incorrect information.
   • The technologist would like to fix the demographics on the image either before or after (depending upon moment of discovery) images are sent to PACS and workstations.
   • Note: these errors may also be in the prior exam images retrieved from PACS. One technologist comment that in one facility, she was able to correct some years in PACS, but not others??
5. Demographic errors II
   • During an exam, the patient commented that the DOB was not correct on her images (not sure if current or prior)
   • The technologist attempted to correct the DOB at the PACS (a remote disaster recovery – type PACS).
   • DOB corrections appeared to take, however, 24 hours afterwards, the correction was gone.
   • The tech wonders if the problem had to do with being able to correct the DOB on the local cache, but the long term archive did not correct.
6. Multiple MRN’s of the same patient
   • Sometimes the facility (or the patient during registration) does not realize that a patient has already been registered within that facility. This could be due to a simple name change which is common in women’s healthcare.
   • Technologist have experienced systems which do not facilitate operations for patients who have the same MRN, but have different names – case where the patient has changed her last name, or a nick name was used in one of the records.
   • Technologists have experienced systems which do not facilitate operations for patients who are the same patient, but have been issued multiple medical record numbers, because the registering agent did not recognize a prior existing record.
   • Technologists and radiologist would like systems that recognize the connection between patient records in the scenarios above and allow a merge function that treats dissimilar demographic identifiers as the same patient.
7. Facilities without RIS:
   • Our applications staff says that they are challenged by following the IHE technical framework for demographic updates. The mammography market place has a significant enough population of providers without RIS’s or RIS to PACS communication, that they desire additional paths for demographic corrections or updates.

Gap Analysis: Worklist Error Use Cases vs. Existing IHE Specifications

Paul Seifert to fill in details here

Corrected Views, Additional views, and Rejected views - Use cases

1. Acquisition taken with wrong view defaults
   • The technologist takes a left breast cranial caudal view (LCC), and didn’t realize that defaults were set for a right breast (RCC) view.
   • Images have already been sent to CAD, PACS, and mammography workstation
   • The technologist would like to correct the image with the proper labeling (view code, view description, patient orientation, laterality, possibly other tags like view modifier, series description).
   • The technologist does not want to re-expose the patient to get a properly labeled LCC, and would like to be able to correct her mistake.
   • The radiologist doesn’t want to miss diagnose a right breast for a left breast
   • The radiologist wants images to be labeled correctly.
   • The radiologist doesn’t want an incorrectly labeled image to be included in her hanging protocol (either hung improperly or labeled improperly)
   • The radiologist would like accurate CAD results with proper hanging on the corrected image and be aware of any incorrect images. Note from technologist: even when given a tool to correct demographics, the CAD does not come out on the corrected images. I believe that this may have something to do with referencing the same original source image as the incorrect image, but I’m not completely sure of the underlying issue, but may have access to CAD, modality, and workstation developers who do understand it.
   • Technologist note: some PACS don’t seem to take the corrected image, or even with the orientation properly relabeled, still hang the images improperly. I have the name of the PACS, but don’t fully have the detail of the underlying problem. Also, in the instance, the CAD does not hang properly on the corrected image.
   • The facility would like the archived patient record to not confuse any one with its future use (avoid the export and retrieval of improperly labeled images where the technologist and radiologist are unaware of the original mistake – as opposed to current exam mistakes which can be discussed among the tech who made the mistake and the reading radiologist.)
2. Finish additional views in another room:
   • During a diagnostic exam, the technologist must add views after having completed a worklist item. However, the original room is not available, so she uses another room
   • In some facilities the worklist item is no longer available to be selected for use. In other facilities, the worklist item still remains and can be used by the technologist.
   • The technologist would like easy access to the original images, and then acquires the additional views.
   • The technologist stated that they see complications with the MPPS messages in this scenario, but did not elaborate further. Does anyone know if implementations that cause specific issues?
3. Multiple rejected views:
   • While trying to correct demographics on a modality, the technologist ended up with extra copies of rejected views.
   • I have no more specifics, and the tech couldn’t remember exactly how she got in this situation, but the reason for noting this case is to be aware of rejected views, and whether or this group should provide guidance on how to handle rejected views in terms of image availability, views deemed rejected after being sent to store devices, and any effect rejected views should have on MPPS content (to include or not include in the image count and reference sequences)

Gap Analysis: Corrected Views, Additional views, and Rejected views Use Cases vs. Existing IHE Specifications

Paul Seifert to fill in details here

Systems level Concerns – multiple PACS - Use cases

1. PACS supporting multiple facilities:
   • Some PACS vendors are tying together multiple facilities which have overlapping patient ID’s
   • The technologist or radiologist will query on PACS, and see records all attributed to the same name.
   • When the records are retrieved, the patient ID’s are all the same, but the actual names that come with the records have different names, and indeed are different patients.
   • Personal note: I have worked with PACS tying together multiple facilities with different PID schemas and the PACS will respond the PID queries, but strip the PID upon retrieval if the patient doesn’t have a local PID, instead of returning the record with a compatible PID.
2. Facilities with multiple PACS:
   • In some facilities, technologist and radiologist need to pull patient records from a variety of PACS for which they have access. Example – a same “healthcare provider” remote facility (with it’s own PACS) does only screening exams. The patient is referred to another facility (with its own PACS) in the same network, that does diagnostic exams. At the diagnostic site, the staff pulls images from the remote facility PACS
   • The remote PACS and local PACS do not have the same patient and study identifier schema.
   • The technologist and radiologist would like to merge the records to view the images of patient all together.
   • The facilities do not want different patients with the same ID (because of multiple patient domains) to have their records accidentally combined or mixed-up