- Email: [email protected]
IT Tools Needed for Interventional Radiology
BITS AND BYTES
RAMIN KHORASANI, MD, MPH
IT Tools Needed for Interventional Radiology Radiology has benefited substantially from information technology (IT) solutions tailored to our typical work flow needs. Radiology information system (RIS) functionality allowed practices to manage their expensive capital assets (eg, computed tomographic or magnetic resonance imaging scanners) more efficiently. Radiology information systems also enabled the electronic signature of reports and the streamlined generation of finalized radiology reports. They also provided a mechanism for the large-scale distribution of paper reports initially and later enabled the electronic transmission of such reports to electronic medical records (EMRs) at many practices. Picture archiving and communication systems and their optimal implementation (to eliminate paper and film) have also improved our practice. More recently, speech recognition– enabled applications have automated report generation and improved report turnaround time. The great majority of these IT innovations were tailored to address diagnostic imaging work in our specialty. The increasing volume and complexity of minimally invasive procedures performed by radiologists (herein referred to as interventional radiology) have exposed many gaps in our existing IT solutions. To maintain and enhance radiology’s role in this growing and critical aspect of our practice, focused attention and resources (including IT) are needed to streamline, automate, and continually improve the interventional radiologic services we provide our patients. In this column, I highlight some of the major differences in needed functionality that distinguish interventional from diagnostic radiology.
PREPROCEDURE EVALUATION Requests for procedures in interventional radiology in some ways resemble consulting a surgeon. A procedure is not necessarily performed when an interventionalist is asked to review a case. In current practice, the content of this evaluation can be as formal as a surgical consult (eg, a preprocedure clinic visit for liver tumor ablation) or as informal as an evaluation of a brief history provided by a referring physician or a review of current imaging and pertinent laboratory results or other components of the medical record for assessment before a percutaneous liver biopsy. If a clinic visit is required, the visit should be scheduled so that the physician performing the procedure (optimally) can assess the patient, describe the procedure to the patient, answer the patient’s questions, and obtain informed consent and necessary laboratory tests. Optimally, each preprocedure evaluation should be documented as a physician note and submitted to the patient’s medical record. This consultation note is then available to the community of physicians who care for the patient. In particular, if a procedure is deemed unnecessary for whatever reason, the radiologist’s note in the medical record will establish the radiologist’s opinion on the appropriate management of the patient. Radiology information system products are ill suited to adequately provide the IT infrastructure for preprocedure assessment and documentation. Managing clinic scheduling for multiple interventionalists, making clinic schedules easily accessible to them, and allowing seamless access to each clinic patient’s medical record
© 2007 American College of Radiology 0091-2182/07/$32.00 ● DOI 10.1016/j.jacr.2007.07.010
so they can be easily reviewed in the context of the clinic visit are functions typically provided by EMR products, not the IT products traditionally servicing radiology. Such EMR solutions optimally allow for the electronic documentation of clinic visits, both for ensuring quality and for enabling billing processes to ensue. The ordering of needed laboratory tests or diagnostic imaging before a procedure can also be enabled with computerized physician order entry components embedded in the EMR. Thus, an optimum EMR product is much better suited to address the preprocedure evaluation needs of interventional radiology than an RIS. Even if radiology practices attempt to embed the preprocedure documentation in RIS, notes will not be archived appropriately with other physician consults in the EMR and would typically file with radiology reports unless more sophisticated integration between RIS and the EMR is undertaken. PROCEDURE SCHEDULING Diagnostic imaging typically requires scheduling an image acquisition device using RIS resource-based scheduling. Assuming that technologist time is equivalently scheduled, a diagnostic procedure can be performed. For interventional procedures, a nurse, other specialized equipment (such as an ultrasound unit), and even a specific interventionalist would need to be scheduled in addition to an acquisition device and a technologist. In essence, it is necessary to deal with scheduling an interventional “event” with multiple valuable and limited resources. Such scheduled events would need to be viewable from various perspectives, 723
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such as interventionalists, nurses, equipment, technologists, and so on, and all conflicts identified electronically so they can be managed effectively. This challenge becomes broader as interventional procedures become dispersed throughout a radiology department because of the distribution of capital intensive assets such as computed tomographic or magnetic resonance imaging scanners. The event scheduler must have Digital Imaging and Communications in Medicine modality work list functionality (the ability to send standard electronic messages to the image acquisition device so that patient identifiers are accurately represented in the Digital Imaging ⬎and Communications in Medicine header). During the day of the procedure, a dynamically changing electronic display should displace the ever present white boards so that procedure progress can be tracked and information made available as needed to downstream applications (eg, applications that help manage recovery rooms for nursing staff members). Thus, optimal event scheduling for interventional procedures requires more complex functionality and integration capability than is available from most RIS products today. INTRAPROCEDURAL FUNCTIONALITY Policy and procedure checklists should be followed using computergenerated messages so they can be documented in the electronic record as part of the overall acute care documentation (eg, to ensure right patient and right procedure). The procedure should optimally have two reports. The nursing report details the time and dosage of medications, fluids, contrast administered, patient vital signs, a nursing account of the proce-
dure, possible complications, instructions for postprocedural care, and other clinical detail important for downstream care of the patient in the recovery room or on admission to the patient floor. Patient monitoring devices should communicate necessary data to the nursing application so that duplicate data entry is avoided. A radiologistapplicationshouldstreamline detail reporting by capturing medication doses, devices used during the procedure, and so on, to avoid duplicate data entry or erroneous documentation. Capturing device use can also streamline inventory management and eventual billing. Reports should flow electronically to downstream applications for radiologist reports, nursing reports, billing interfaces, and so on. POSTPROCEDURE FUNCTIONALITY Medication reconciliation will ensure that patients are discharged with the appropriate complement of medications. There is a need to document complications for quality, safety, and even regulatory reporting [1]. The ability to schedule follow-up clinic visits (eg, for catheter care or removal) is important. This function will also require the creation of various patient lists (eg, all those with catheters) so that communication handoffs among members of the interventional care team are effective. The documentation of all follow-up visits in the medical record is necessary, and not just for billing purposes. In this part of the process, an application or database focused on the documentation and follow-up of complications, as well as an optimal EMR product (similar in function to preprocedure scheduling, documentation, etc), becomes a necessity.
CONCLUSION As is apparent in this very brief overview, there are numerous functional gaps in our current IT solutions if we were to simply apply diagnostic radiology IT tools to interventional radiology. In this overview, I have not discussed image management requirements (eg, digital subtraction functions necessary for vascular work, still missing from many picture archiving and communication systems). Many of the functions described above are managed in current practice by various paper-based processes, at times ineffectively. To help expand and enhance the quality, safety, and efficiency of the interventional radiology services we provide for our patients, it is imperative to effectively and appropriately automate many processes. The adoption of EMR products similar to those used by other specialties will be an important element of this automation. Because of its complexity and relatively small volume, most IT vendors have not resourced suitable product development for interventional radiology to date. However, it is unlikely that a single product will meet the varied functions described above. The optimal implementation of solutions will undoubtedly require the seamless integration of many IT products. Expanding the scope and scale of interventional radiologic services without adequate automation could prove to be difficult. REFERENCE 1. Hahn PF, Lee MJ, Gazelle GS, Forman BH, Mueller PR. A simplified HyperCard data base for patient management in an interventional practice: experience with more than 4000 cases. AJR Am J Roentgenol 1994;162: 1443-6.
Ramin Khorasani, MD, MPH, Department of Radiology and Center for Evidence-Based Imaging, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115e-mail: [email protected].
RAMIN KHORASANI, MD, MPH
IT Tools Needed for Interventional Radiology Radiology has benefited substantially from information technology (IT) solutions tailored to our typical work flow needs. Radiology information system (RIS) functionality allowed practices to manage their expensive capital assets (eg, computed tomographic or magnetic resonance imaging scanners) more efficiently. Radiology information systems also enabled the electronic signature of reports and the streamlined generation of finalized radiology reports. They also provided a mechanism for the large-scale distribution of paper reports initially and later enabled the electronic transmission of such reports to electronic medical records (EMRs) at many practices. Picture archiving and communication systems and their optimal implementation (to eliminate paper and film) have also improved our practice. More recently, speech recognition– enabled applications have automated report generation and improved report turnaround time. The great majority of these IT innovations were tailored to address diagnostic imaging work in our specialty. The increasing volume and complexity of minimally invasive procedures performed by radiologists (herein referred to as interventional radiology) have exposed many gaps in our existing IT solutions. To maintain and enhance radiology’s role in this growing and critical aspect of our practice, focused attention and resources (including IT) are needed to streamline, automate, and continually improve the interventional radiologic services we provide our patients. In this column, I highlight some of the major differences in needed functionality that distinguish interventional from diagnostic radiology.
PREPROCEDURE EVALUATION Requests for procedures in interventional radiology in some ways resemble consulting a surgeon. A procedure is not necessarily performed when an interventionalist is asked to review a case. In current practice, the content of this evaluation can be as formal as a surgical consult (eg, a preprocedure clinic visit for liver tumor ablation) or as informal as an evaluation of a brief history provided by a referring physician or a review of current imaging and pertinent laboratory results or other components of the medical record for assessment before a percutaneous liver biopsy. If a clinic visit is required, the visit should be scheduled so that the physician performing the procedure (optimally) can assess the patient, describe the procedure to the patient, answer the patient’s questions, and obtain informed consent and necessary laboratory tests. Optimally, each preprocedure evaluation should be documented as a physician note and submitted to the patient’s medical record. This consultation note is then available to the community of physicians who care for the patient. In particular, if a procedure is deemed unnecessary for whatever reason, the radiologist’s note in the medical record will establish the radiologist’s opinion on the appropriate management of the patient. Radiology information system products are ill suited to adequately provide the IT infrastructure for preprocedure assessment and documentation. Managing clinic scheduling for multiple interventionalists, making clinic schedules easily accessible to them, and allowing seamless access to each clinic patient’s medical record
© 2007 American College of Radiology 0091-2182/07/$32.00 ● DOI 10.1016/j.jacr.2007.07.010
so they can be easily reviewed in the context of the clinic visit are functions typically provided by EMR products, not the IT products traditionally servicing radiology. Such EMR solutions optimally allow for the electronic documentation of clinic visits, both for ensuring quality and for enabling billing processes to ensue. The ordering of needed laboratory tests or diagnostic imaging before a procedure can also be enabled with computerized physician order entry components embedded in the EMR. Thus, an optimum EMR product is much better suited to address the preprocedure evaluation needs of interventional radiology than an RIS. Even if radiology practices attempt to embed the preprocedure documentation in RIS, notes will not be archived appropriately with other physician consults in the EMR and would typically file with radiology reports unless more sophisticated integration between RIS and the EMR is undertaken. PROCEDURE SCHEDULING Diagnostic imaging typically requires scheduling an image acquisition device using RIS resource-based scheduling. Assuming that technologist time is equivalently scheduled, a diagnostic procedure can be performed. For interventional procedures, a nurse, other specialized equipment (such as an ultrasound unit), and even a specific interventionalist would need to be scheduled in addition to an acquisition device and a technologist. In essence, it is necessary to deal with scheduling an interventional “event” with multiple valuable and limited resources. Such scheduled events would need to be viewable from various perspectives, 723
724 Bits and Bytes
such as interventionalists, nurses, equipment, technologists, and so on, and all conflicts identified electronically so they can be managed effectively. This challenge becomes broader as interventional procedures become dispersed throughout a radiology department because of the distribution of capital intensive assets such as computed tomographic or magnetic resonance imaging scanners. The event scheduler must have Digital Imaging and Communications in Medicine modality work list functionality (the ability to send standard electronic messages to the image acquisition device so that patient identifiers are accurately represented in the Digital Imaging ⬎and Communications in Medicine header). During the day of the procedure, a dynamically changing electronic display should displace the ever present white boards so that procedure progress can be tracked and information made available as needed to downstream applications (eg, applications that help manage recovery rooms for nursing staff members). Thus, optimal event scheduling for interventional procedures requires more complex functionality and integration capability than is available from most RIS products today. INTRAPROCEDURAL FUNCTIONALITY Policy and procedure checklists should be followed using computergenerated messages so they can be documented in the electronic record as part of the overall acute care documentation (eg, to ensure right patient and right procedure). The procedure should optimally have two reports. The nursing report details the time and dosage of medications, fluids, contrast administered, patient vital signs, a nursing account of the proce-
dure, possible complications, instructions for postprocedural care, and other clinical detail important for downstream care of the patient in the recovery room or on admission to the patient floor. Patient monitoring devices should communicate necessary data to the nursing application so that duplicate data entry is avoided. A radiologistapplicationshouldstreamline detail reporting by capturing medication doses, devices used during the procedure, and so on, to avoid duplicate data entry or erroneous documentation. Capturing device use can also streamline inventory management and eventual billing. Reports should flow electronically to downstream applications for radiologist reports, nursing reports, billing interfaces, and so on. POSTPROCEDURE FUNCTIONALITY Medication reconciliation will ensure that patients are discharged with the appropriate complement of medications. There is a need to document complications for quality, safety, and even regulatory reporting [1]. The ability to schedule follow-up clinic visits (eg, for catheter care or removal) is important. This function will also require the creation of various patient lists (eg, all those with catheters) so that communication handoffs among members of the interventional care team are effective. The documentation of all follow-up visits in the medical record is necessary, and not just for billing purposes. In this part of the process, an application or database focused on the documentation and follow-up of complications, as well as an optimal EMR product (similar in function to preprocedure scheduling, documentation, etc), becomes a necessity.
CONCLUSION As is apparent in this very brief overview, there are numerous functional gaps in our current IT solutions if we were to simply apply diagnostic radiology IT tools to interventional radiology. In this overview, I have not discussed image management requirements (eg, digital subtraction functions necessary for vascular work, still missing from many picture archiving and communication systems). Many of the functions described above are managed in current practice by various paper-based processes, at times ineffectively. To help expand and enhance the quality, safety, and efficiency of the interventional radiology services we provide for our patients, it is imperative to effectively and appropriately automate many processes. The adoption of EMR products similar to those used by other specialties will be an important element of this automation. Because of its complexity and relatively small volume, most IT vendors have not resourced suitable product development for interventional radiology to date. However, it is unlikely that a single product will meet the varied functions described above. The optimal implementation of solutions will undoubtedly require the seamless integration of many IT products. Expanding the scope and scale of interventional radiologic services without adequate automation could prove to be difficult. REFERENCE 1. Hahn PF, Lee MJ, Gazelle GS, Forman BH, Mueller PR. A simplified HyperCard data base for patient management in an interventional practice: experience with more than 4000 cases. AJR Am J Roentgenol 1994;162: 1443-6.
Ramin Khorasani, MD, MPH, Department of Radiology and Center for Evidence-Based Imaging, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115e-mail: [email protected].