- Email: [email protected]
Real-Time Electronic Dashboard Technology and Its Use to Improve Pediatric Radiology Workflow
Current Problems in Diagnostic Radiology ] (2017) ]]]–]]]
Current Problems in Diagnostic Radiology journal homepage: www.cpdrjournal.com
Real-Time Electronic Dashboard Technology and Its Use to Improve Pediatric Radiology Workflow Randheer Shailam, MDn, Ariel Botwin, BS, Markus Stout, BS, MBA, Michael S. Gee, MD, PhD Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
The purpose of our study was to create a real-time electronic dashboard in the pediatric radiology reading room providing a visual display of updated information regarding scheduled and in-progress radiology examinations that could help radiologists to improve clinical workflow and efficiency. To accomplish this, a script was set up to automatically send real-time HL7 messages from the radiology information system (Epic Systems, Verona, WI) to an Iguana Interface engine, with relevant data regarding examinations stored in an SQL Server database for visual display on the dashboard. Implementation of an electronic dashboard in the reading room of a pediatric radiology academic practice has led to several improvements in clinical workflow, including decreasing the time interval for radiologist protocol entry for computed tomography or magnetic resonance imaging examinations as well as fewer telephone calls related to unprotocoled examinations. Other advantages include enhanced ability of radiologists to anticipate and attend to examinations requiring radiologist monitoring or scanning, as well as to work with technologists and operations managers to optimize scheduling in radiology resources. We foresee increased utilization of electronic dashboard technology in the future as a method to improve radiology workflow and quality of patient care. & 2017 Elsevier Inc. All rights reserved.
Introduction Workflow and efficiency go hand in hand and optimizing both is vital to the practice of radiology. In addition to interpreting diagnostic imaging examinations, radiologists develop and modify imaging protocols for specific patients and study indications, particularly for computed tomography (CT) and magnetic resonance imaging (MRI) examinations, to ensure that the anatomical coverage and imaging technique are tailored to address the relevant clinical indication for each study. Although in adult patients, most radiology protocols are standard and rarely require modification, in pediatric patients imaging protocols are much more individualized, based not only on the study indication but also on the age of the patient as well as other developmental factors. Despite the transition to digital imaging and voice recognition software for dictation within the last 2 decades that has improved workflow efficiency for radiologists, clinical responsibilities continue to increase because of expanded roles in areas beyond interpreting studies as well as the increased number of imaging studies ordered for patient care. Some of these new roles include increased communication with referring clinicians, technologist supervision, and inperson consultations. Telephone communication, including calls with technologists regarding study protocols and with ordering physicians regarding imaging findings, is a vital responsibility of radiologists but has the potential to interrupt n Reprint requests: Randheer Shailam, MD, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114. E-mail address: [email protected] (R. Shailam) E-mail address: [email protected] (R. Shailam).
http://dx.doi.org/10.1067/j.cpradiol.2017.03.002 0363-0188/& 2017 Elsevier Inc. All rights reserved.
clinical workflow. A previous study found that, at peak times, the time interval between telephone calls to radiologists in the reading room can be as low as 4 minutes.1 Frequent telephone calls interrupt radiologist interpretation of examinations and have the potential to affect the quality of radiology reports.2 Additional responsibilities involved with image acquisition require radiologists to leave the interpretation area, including CT or MRI study monitoring and ultrasound (US) scanning, during which time the radiologist is not available for study interpretation or fielding telephone calls.3 The cumulative effect of these increasing responsibilities is to decrease efficiency of radiologist interpretation of studies, raise the likelihood of multiple tasks arriving simultaneously with delayed performance of one or more tasks, and introduce potential sources of error into a busy clinical practice. For these reasons, it would be advantageous for pediatric radiologists to have up to date knowledge of scheduled and in-progress radiology examinations to anticipate and prevent problems before they happen. One solution would be a daily display of scheduled and in-progress imaging studies that updates in real-time and can be easily viewed by the radiologist on service. This list would provide radiologists with important information about the patients, examination type and location, and protocol, as well as level of acuity. For example, knowing as soon as an urgent add-on MRI is scheduled ensures that the correct protocol is entered promptly and that the correct resource (eg, field strength and availability of magnetic resonance (MR)-compatible goggles) can be used. Tracking in-progress examinations also allows radiologists to work with technologists and operations managers to optimize clinical workflow by identifying resources that are ahead and behind schedule. Finally, a real-time updated list of studies
2
R. Shailam et al. / Current Problems in Diagnostic Radiology ] (2017) ]]]–]]]
information system (RIS), which tracks patient scheduling, resource management, and procedure billing for radiology departments.4 One advantage of a RIS-based radiologist workflow algorithm is that the RIS is already built to track radiology examination order entry as well as patient progress in radiology.5 Our goal was to create a real-time updated electronic dashboard to track and display scheduled and in-progress pediatric radiology examinations.
Materials and Methods
Fig. 1. Schematic diagram of dashboard-RIS interface.
would help radiologists to anticipate workflow problems by highlighting studies requiring radiologist performance (eg, monitoring or scanning) in addition to interpretation. This would in turn help to minimize examination delays as well as extra phone calls from technologists, nurses, and patients. Current daily workflow for radiologists is centered on the Picture Archiving and Communication System (PACS), with radiologists tracking real-time updated worklists on PACS displaying completed examinations to be interpreted. However, PACS-based worklists do not allow tracking of imaging studies that are not yet performed. This type of information is available in the radiology
Referring clinicians and staff order and schedule radiology examinations in Epic Systems (Verona Wisconsin). Examination orders trigger immediate HL7 messages sent from Epic to an Iguana Interface engine managed by the radiology department. Other events, such as patient arrival, begin examination, and end examination times also trigger additional messages. The order and schedule messages are processed and stored in a Microsoft SQL Server (SQL Compliant) database. The SQL server records relevant order information such as patient demographics (age, MRN, and accession), examination information (examination code, schedule date, and performing resource), and other data about the order (ordering physician, anesthesia, arrival time, study status, etc.) The SQL database is constantly updated by new incoming HL7 messages from Epic, maintaining a near real-time data source. The radiology department uses the SQL Compliant database as a platform to develop various software programs designed to augment the practice of radiology. The applications include a protocol assignment system used to protocol CT and MR orders and a PACS worklist assignment system, used to assign a procedure to the correct
Fig. 2. Screenshot of electronic dashboard. (Color version of figure is available online.)
R. Shailam et al. / Current Problems in Diagnostic Radiology ] (2017) ]]]–]]]
3
Table Ways in which an electronic dashboard improves radiologist’s efficiency as well as clinical workflow Electronic dashboard metrics tracked in real time
Effect on clinical workflow
Same day add-on scheduled examinations Radiology examination resources Patient status Patient wait time Examination start time
Decrease time interval to radiologist protocol entry Increased ability to rearrange scheduled examinations among resources, improved resource allocation Improved ability to insert add-on inpatient studies into different resources Decrease patient wait times, more efficient resource utilization Decrease time interval to radiologist performance/monitoring of studies
radiologist. The protocol and worklist assignment applications store additional data to SQL compliant databases that can be queried along with the order and schedule information received from Epic. Using a Logi Analytics Logi Info Business Analytics system, the collection of SQL databases managed are queried every 90 seconds to generate an intuitive dashboard view that highlights pediatric studies to be performed on a given day (Fig. 1). The dashboard, published as a web page, is viewed in the pediatric radiology reading room. The web pages are refreshed every 90 seconds to display the latest information available for each order, allowing the radiologists to monitor and react to patient activity in a timely manner.
cases, both of which suggest an improvement in workflow for radiologists and technologists (A Botwin, unpublished results). In addition, our pediatric radiologists have been able to use the examination start times to anticipate when they will be needed to perform or monitor nonstandard US and MRI studies, which further improves efficiency and decreases overall examination times. Finally, by getting updated information on patient wait times, radiologists are able to play a more active role in expediting workflow in conjunction with technologists and patient care coordinators.
Results
Introduction of an electronic dashboard into our pediatric radiology clinical practice has several benefits (summarized in the Table). The numerous metrics that are recorded in the RIS, including patient status, radiology resource, and examination scheduled and start times, can be leveraged by radiologists to improve clinical workflow and efficiency using a real-time updated visual display of scheduled and in-progress examinations. Improvements in workflow include decreasing time intervals for radiologist protocoling, monitoring, and scanning examinations, as well as decreased patient wait and examination times and improved resource utilization. These in turn are expected to improve diagnostic accuracy and quality of patient care. We believe that the use of real-time electronic dashboard technology has great potential for enhancing the practice of radiology and that it should see increased application in the near future.
We set up the dashboard to mimic our daily assignments (Fig. 2). At our institution, we have one attending pediatric radiologist whose responsibility is to interpret MRI, CT, positron emission tomography, and radiographs. For this assignment, we decided to include MRI and CT studies at the top of our dashboard because they are the modalities most likely to require active protocoling and monitoring. Any studies that require urgent or STAT interpretation would be highlighted on the PACS worklist after the study was completed. A second pediatric radiologist is responsible for US and fluoroscopy examinations and those two modalities are tracked on the dashboard below MR and CT. The total numbers of scheduled or in-progress studies for each modality are displayed in large font on the left side of the dashboard. Each row on the dashboard corresponds to an examination within the modality indicated by the total number. Columns indicate examination status (scheduled or in progress); patient name, age, and medical record number; patient status (inpatient, outpatient, or arrived in radiology); times of examination scheduling, patient arrival, and examination start; examination code; resource; and protocol status (protocol needed or protocol selected by the radiologist). The examinations on the dashboard are also color-coded for easy recognition. Examinations in need of protocolling are noted in red, examinations in progress, green, and when a patient is waiting, yellow. Examinations performed under anesthesia are indicated in blue. When examinations are completed in RIS, they disappear from the dashboard. The electronic dashboard is displayed on a large flat screen monitor above the PACS workstations on one side of the reading room, and is easily visible from all sides of the room. Upon entering the reading room, the pediatric radiologists at a glance can see how many examinations of each modality type are scheduled or in-progress. As the dashboard is updated every 90 seconds, we are able to see any add-on examinations throughout the day across the modalities and protocol cases as they are scheduled. This minimizes the delay for radiologist protocoling of studies and decreases the need for MR and CT technologists to call into the reading room to discuss unprotocoled examinations. Our preliminary analysis indicates that the introduction of the electronic dashboard has led to a reduction in both time between examination scheduling and protocoling as well as number of phone calls into the reading room to discuss unprotocoled CT or MR
Discussion
Conclusions The use of a real-time electronic dashboard can improve clinical workflow in pediatric radiology. Potential benefits include the following: (1) Decreased time interval to radiologist protocoling, monitoring, and scanning examinations. (2) Improved radiology resource use and decreased examination wait times. (3) Fewer examination-related interruptions with improved radiologist ability to focus on examination interpretation.
References 1. Yu JP, Kansagra AP, Mongan J. The radiologist’s workflow environment: Evaluation of disruptors and potential implications. J Am Coll Radiol 2014;11 (6):589–93. 2. Balint BJ, Steenburg SD, Lin H, et al. Do telephone call interruptions have an impact on radiology resident diagnostic accuracy? Acad Radiol 2014;21(12):1623–8. 3. Larson DB, Froehle CM, Johnson ND, et al. Communication in diagnostic radiology: Meeting the challenges of complexity. AJR Am J Roentgenol 2014;203(5):957–64. 4. McEnery KW. Coordinating patient care within radiology and across enterprise. J Am Coll Radiol 2014;11(12 Pt B):1217–25. 5. Society for Informatics in Medicine. SIIM workflow initiative in medicine. Available at: http://siim.org/innovation/siim-workflow-initiative-medicineswim.
Current Problems in Diagnostic Radiology journal homepage: www.cpdrjournal.com
Real-Time Electronic Dashboard Technology and Its Use to Improve Pediatric Radiology Workflow Randheer Shailam, MDn, Ariel Botwin, BS, Markus Stout, BS, MBA, Michael S. Gee, MD, PhD Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
The purpose of our study was to create a real-time electronic dashboard in the pediatric radiology reading room providing a visual display of updated information regarding scheduled and in-progress radiology examinations that could help radiologists to improve clinical workflow and efficiency. To accomplish this, a script was set up to automatically send real-time HL7 messages from the radiology information system (Epic Systems, Verona, WI) to an Iguana Interface engine, with relevant data regarding examinations stored in an SQL Server database for visual display on the dashboard. Implementation of an electronic dashboard in the reading room of a pediatric radiology academic practice has led to several improvements in clinical workflow, including decreasing the time interval for radiologist protocol entry for computed tomography or magnetic resonance imaging examinations as well as fewer telephone calls related to unprotocoled examinations. Other advantages include enhanced ability of radiologists to anticipate and attend to examinations requiring radiologist monitoring or scanning, as well as to work with technologists and operations managers to optimize scheduling in radiology resources. We foresee increased utilization of electronic dashboard technology in the future as a method to improve radiology workflow and quality of patient care. & 2017 Elsevier Inc. All rights reserved.
Introduction Workflow and efficiency go hand in hand and optimizing both is vital to the practice of radiology. In addition to interpreting diagnostic imaging examinations, radiologists develop and modify imaging protocols for specific patients and study indications, particularly for computed tomography (CT) and magnetic resonance imaging (MRI) examinations, to ensure that the anatomical coverage and imaging technique are tailored to address the relevant clinical indication for each study. Although in adult patients, most radiology protocols are standard and rarely require modification, in pediatric patients imaging protocols are much more individualized, based not only on the study indication but also on the age of the patient as well as other developmental factors. Despite the transition to digital imaging and voice recognition software for dictation within the last 2 decades that has improved workflow efficiency for radiologists, clinical responsibilities continue to increase because of expanded roles in areas beyond interpreting studies as well as the increased number of imaging studies ordered for patient care. Some of these new roles include increased communication with referring clinicians, technologist supervision, and inperson consultations. Telephone communication, including calls with technologists regarding study protocols and with ordering physicians regarding imaging findings, is a vital responsibility of radiologists but has the potential to interrupt n Reprint requests: Randheer Shailam, MD, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114. E-mail address: [email protected] (R. Shailam) E-mail address: [email protected] (R. Shailam).
http://dx.doi.org/10.1067/j.cpradiol.2017.03.002 0363-0188/& 2017 Elsevier Inc. All rights reserved.
clinical workflow. A previous study found that, at peak times, the time interval between telephone calls to radiologists in the reading room can be as low as 4 minutes.1 Frequent telephone calls interrupt radiologist interpretation of examinations and have the potential to affect the quality of radiology reports.2 Additional responsibilities involved with image acquisition require radiologists to leave the interpretation area, including CT or MRI study monitoring and ultrasound (US) scanning, during which time the radiologist is not available for study interpretation or fielding telephone calls.3 The cumulative effect of these increasing responsibilities is to decrease efficiency of radiologist interpretation of studies, raise the likelihood of multiple tasks arriving simultaneously with delayed performance of one or more tasks, and introduce potential sources of error into a busy clinical practice. For these reasons, it would be advantageous for pediatric radiologists to have up to date knowledge of scheduled and in-progress radiology examinations to anticipate and prevent problems before they happen. One solution would be a daily display of scheduled and in-progress imaging studies that updates in real-time and can be easily viewed by the radiologist on service. This list would provide radiologists with important information about the patients, examination type and location, and protocol, as well as level of acuity. For example, knowing as soon as an urgent add-on MRI is scheduled ensures that the correct protocol is entered promptly and that the correct resource (eg, field strength and availability of magnetic resonance (MR)-compatible goggles) can be used. Tracking in-progress examinations also allows radiologists to work with technologists and operations managers to optimize clinical workflow by identifying resources that are ahead and behind schedule. Finally, a real-time updated list of studies
2
R. Shailam et al. / Current Problems in Diagnostic Radiology ] (2017) ]]]–]]]
information system (RIS), which tracks patient scheduling, resource management, and procedure billing for radiology departments.4 One advantage of a RIS-based radiologist workflow algorithm is that the RIS is already built to track radiology examination order entry as well as patient progress in radiology.5 Our goal was to create a real-time updated electronic dashboard to track and display scheduled and in-progress pediatric radiology examinations.
Materials and Methods
Fig. 1. Schematic diagram of dashboard-RIS interface.
would help radiologists to anticipate workflow problems by highlighting studies requiring radiologist performance (eg, monitoring or scanning) in addition to interpretation. This would in turn help to minimize examination delays as well as extra phone calls from technologists, nurses, and patients. Current daily workflow for radiologists is centered on the Picture Archiving and Communication System (PACS), with radiologists tracking real-time updated worklists on PACS displaying completed examinations to be interpreted. However, PACS-based worklists do not allow tracking of imaging studies that are not yet performed. This type of information is available in the radiology
Referring clinicians and staff order and schedule radiology examinations in Epic Systems (Verona Wisconsin). Examination orders trigger immediate HL7 messages sent from Epic to an Iguana Interface engine managed by the radiology department. Other events, such as patient arrival, begin examination, and end examination times also trigger additional messages. The order and schedule messages are processed and stored in a Microsoft SQL Server (SQL Compliant) database. The SQL server records relevant order information such as patient demographics (age, MRN, and accession), examination information (examination code, schedule date, and performing resource), and other data about the order (ordering physician, anesthesia, arrival time, study status, etc.) The SQL database is constantly updated by new incoming HL7 messages from Epic, maintaining a near real-time data source. The radiology department uses the SQL Compliant database as a platform to develop various software programs designed to augment the practice of radiology. The applications include a protocol assignment system used to protocol CT and MR orders and a PACS worklist assignment system, used to assign a procedure to the correct
Fig. 2. Screenshot of electronic dashboard. (Color version of figure is available online.)
R. Shailam et al. / Current Problems in Diagnostic Radiology ] (2017) ]]]–]]]
3
Table Ways in which an electronic dashboard improves radiologist’s efficiency as well as clinical workflow Electronic dashboard metrics tracked in real time
Effect on clinical workflow
Same day add-on scheduled examinations Radiology examination resources Patient status Patient wait time Examination start time
Decrease time interval to radiologist protocol entry Increased ability to rearrange scheduled examinations among resources, improved resource allocation Improved ability to insert add-on inpatient studies into different resources Decrease patient wait times, more efficient resource utilization Decrease time interval to radiologist performance/monitoring of studies
radiologist. The protocol and worklist assignment applications store additional data to SQL compliant databases that can be queried along with the order and schedule information received from Epic. Using a Logi Analytics Logi Info Business Analytics system, the collection of SQL databases managed are queried every 90 seconds to generate an intuitive dashboard view that highlights pediatric studies to be performed on a given day (Fig. 1). The dashboard, published as a web page, is viewed in the pediatric radiology reading room. The web pages are refreshed every 90 seconds to display the latest information available for each order, allowing the radiologists to monitor and react to patient activity in a timely manner.
cases, both of which suggest an improvement in workflow for radiologists and technologists (A Botwin, unpublished results). In addition, our pediatric radiologists have been able to use the examination start times to anticipate when they will be needed to perform or monitor nonstandard US and MRI studies, which further improves efficiency and decreases overall examination times. Finally, by getting updated information on patient wait times, radiologists are able to play a more active role in expediting workflow in conjunction with technologists and patient care coordinators.
Results
Introduction of an electronic dashboard into our pediatric radiology clinical practice has several benefits (summarized in the Table). The numerous metrics that are recorded in the RIS, including patient status, radiology resource, and examination scheduled and start times, can be leveraged by radiologists to improve clinical workflow and efficiency using a real-time updated visual display of scheduled and in-progress examinations. Improvements in workflow include decreasing time intervals for radiologist protocoling, monitoring, and scanning examinations, as well as decreased patient wait and examination times and improved resource utilization. These in turn are expected to improve diagnostic accuracy and quality of patient care. We believe that the use of real-time electronic dashboard technology has great potential for enhancing the practice of radiology and that it should see increased application in the near future.
We set up the dashboard to mimic our daily assignments (Fig. 2). At our institution, we have one attending pediatric radiologist whose responsibility is to interpret MRI, CT, positron emission tomography, and radiographs. For this assignment, we decided to include MRI and CT studies at the top of our dashboard because they are the modalities most likely to require active protocoling and monitoring. Any studies that require urgent or STAT interpretation would be highlighted on the PACS worklist after the study was completed. A second pediatric radiologist is responsible for US and fluoroscopy examinations and those two modalities are tracked on the dashboard below MR and CT. The total numbers of scheduled or in-progress studies for each modality are displayed in large font on the left side of the dashboard. Each row on the dashboard corresponds to an examination within the modality indicated by the total number. Columns indicate examination status (scheduled or in progress); patient name, age, and medical record number; patient status (inpatient, outpatient, or arrived in radiology); times of examination scheduling, patient arrival, and examination start; examination code; resource; and protocol status (protocol needed or protocol selected by the radiologist). The examinations on the dashboard are also color-coded for easy recognition. Examinations in need of protocolling are noted in red, examinations in progress, green, and when a patient is waiting, yellow. Examinations performed under anesthesia are indicated in blue. When examinations are completed in RIS, they disappear from the dashboard. The electronic dashboard is displayed on a large flat screen monitor above the PACS workstations on one side of the reading room, and is easily visible from all sides of the room. Upon entering the reading room, the pediatric radiologists at a glance can see how many examinations of each modality type are scheduled or in-progress. As the dashboard is updated every 90 seconds, we are able to see any add-on examinations throughout the day across the modalities and protocol cases as they are scheduled. This minimizes the delay for radiologist protocoling of studies and decreases the need for MR and CT technologists to call into the reading room to discuss unprotocoled examinations. Our preliminary analysis indicates that the introduction of the electronic dashboard has led to a reduction in both time between examination scheduling and protocoling as well as number of phone calls into the reading room to discuss unprotocoled CT or MR
Discussion
Conclusions The use of a real-time electronic dashboard can improve clinical workflow in pediatric radiology. Potential benefits include the following: (1) Decreased time interval to radiologist protocoling, monitoring, and scanning examinations. (2) Improved radiology resource use and decreased examination wait times. (3) Fewer examination-related interruptions with improved radiologist ability to focus on examination interpretation.
References 1. Yu JP, Kansagra AP, Mongan J. The radiologist’s workflow environment: Evaluation of disruptors and potential implications. J Am Coll Radiol 2014;11 (6):589–93. 2. Balint BJ, Steenburg SD, Lin H, et al. Do telephone call interruptions have an impact on radiology resident diagnostic accuracy? Acad Radiol 2014;21(12):1623–8. 3. Larson DB, Froehle CM, Johnson ND, et al. Communication in diagnostic radiology: Meeting the challenges of complexity. AJR Am J Roentgenol 2014;203(5):957–64. 4. McEnery KW. Coordinating patient care within radiology and across enterprise. J Am Coll Radiol 2014;11(12 Pt B):1217–25. 5. Society for Informatics in Medicine. SIIM workflow initiative in medicine. Available at: http://siim.org/innovation/siim-workflow-initiative-medicineswim.