Mapping modalities, defining workflows
With images coming from so many domains of the patient’s care, there is a great diversity of formats that must be managed, stored and accessible in the Enterprise Imaging platform.
“Departments work in different ways and use different modalities: some support DICOM and DICOM worklists, others only support jpg, or can only print,” explains Toon de Clercq, application specialist, Image Management.
“When we are preparing to connect a department, we talk with the people to inventory the kinds of exams they perform, how the department works and what their needs are. This can be very precise, for example the order in which they want to see the images from a specific study. We check whether the exams are being requested and who is requesting them, and how the modality stores the images.
Then we decide how to archive the modality’s images in DICOM, we create procedure codes and we give our colleagues in the department demos and training.” “It isn’t always easy to find the right contact persons for each department,” adds Varsha Birdja, application specialist, Image Management. “There can be a different person for each modality.”
The group defined eight generic workflows; each device is mapped to one of these. “When we go into a new department, this helps us determine how to proceed and what to ask. And when we have implemented a specific workflow in one department, we can then reuse it in another,” Varsha continues. The workflow for uploading CDs is also a key attention point for the hospitals. “Our hospitals receive about 60,000 CDs with images each year (whether sent from referring hospitals or brought by patients), which is about 15% of our total volume of images,” comments Varsha.
“So, this is a very important workflow!” “And some hospitals supply images via third-party digital systems; those have to connect to our system, too,” adds Toon. This workflow has already been implemented in VUmc, and will soon be implemented in AMC.
Finally, there is a special workflow for ‘confidential’ images. “These include images such as those from pediatric psychology: images of children that are thought to have been abused or other very sensitive situations,” highlights Ernest. “The images are kept in the archive, but are only accessible by specific users.
And they are not available through the EMR, but directly via the XERO Viewer.”
Migrating 20 years of images
Already, more than 200 devices have been connected, and the number rises each week, says Ernest. The previous DICOM archive, with 20 years of images, has also been migrated into the Enterprise Imaging platform: “about 4.5 million studies, representing almost half a billion images mainly from radiology, but also from other departments, such as obstetrics/ gynecology.”
One challenge that arose when migrating the exams was ensuring that all studies have the same names. Ernest notes that for some studies, up to 50 different names had been used over the past decades. “We mapped all those different names to one generic study name and procedure code, that is also used in the EMR: instead of thousands of codes, we now have less than 1000 EMR codes. So, all relevant prior studies can be easily retrieved.”
Supported images include:
Anesthesiology, Cardiac Surgery, Dermatology, Gynecology, Gastroenterology, Intensive Care, Pediatric surgery, Nephrology, Neurology, ENT, Pulmonology, Oncology, Orthopedics, Plastic surgery, Radiotherapy, Urology, Blood vessal lab, Obstetrics, …
Efficiency and compromise: a delicate balance
The team started by connecting the ENT (ear, nose and throat), ophthalmology and gastroenterology units, and the vascular lab. Varsha explains, “These departments all had paper-based workflows, which we wanted to eliminate, so they had the highest priority.
Next we connected the radiology images to the VNA, obstetrics and gynecology, cardiology, pulmonary diseases, emergency care, intensive care and pediatrics.” While the new workflows require users to adapt some of their work habits, the team also strives to find ways to compromise.
Toon comments on the issue of exam ordering, for example: “Ophthalmology is now working with requests (or orders), which it didn’t do in the past; the orders are displayed in the modality worklist.
But for gynecology, we know that 95% of all pregnant women visiting the department get an ultrasound. So, based on the type of visit scheduled, we automatically create an order in the background for an ultrasound. If it isn’t performed, it is removed from the worklist at the end of the day, and after five or six days, the order disappears from the system.”
Evolving modalities and devices
The number of modalities to connect continues to grow, though, and the teams have defined procedures for adding them.
“OCT (optical coherence technology), originally used in ophthalmology, is now being used in cardiology as well, so we will connect two OCTs in cardiology. And when we acquire new devices, a crossdepartmental process in the two hospitals makes sure the purchased modalities can be easily connected to the Enterprise Imaging solution.”
Agfa HealthCare’s support has been very important to the success of the project, the colleagues agree: “When we started designing the workflows, we usually had one or two Agfa HealthCare people in our hospital for functional support.
They helped us with migrating the old image archive, which was extremely complex and extensive, and with integrating the Enterprise Imaging platform with the EMR, as well as delivering training to the key users.
We continue to receive on-site support from Agfa HealthCare about one day every two weeks, to help solve current issues and configure new things,” explains Ernest.
Delivering reliable care and reducing errors
There are now around 5,000 users of the system at VUmc, and AMC is getting ready to roll-out the Enterprise Imaging solution as well. “In general, most people find it easy to use, although it was easier for certain users or modalities to make the switch than for others,” comments Varsha.
Toon agrees: “Overall, everybody is happy that the data is digitized and centrally available through the EMR.
The basic idea is to work more efficiently, to deliver reliable care and to decrease errors. Having all the images available on one system for multidisciplinary meetings and boards offers a great advantage in attaining good patient outcomes, too. And finally, with centrally available images, we reduce duplicated exams.
We have also sped up certain exams, for example in ophthalmology a specific modality transferred images of each eye individually, which took quite a while. We adapted the system to transfer the images of the two eyes simultaneously, saving time.”
He concludes, “What I like most about my job now is that I know we are working on something that is very important to the hospital, and ultimately, the patients.”