III.

Workflow in Radiology

1. Genetic Workflow in Radiology and PACS workflow

2. Integrating the Healthcare Enterprise Workflow Model
3. Key steps Radiology Workflow and its Analysis
4. Integration Standards, and Interoperability.
4.1 Integration Challenges and General IT Standards
4.2 IT standards Imaging and Internet Standards.
4.3 DICOM standards
4.4. HL7 Standards
4.5 Interoperability and IHE standards.

==========================================
Genetic Workflow in Radiology and PACS workflow

Radiology is changing rapidly. In the healthcare system – and in radiology as an integral part of it – we
are facing a challenging situation of shrinking budgets, increasing cost pressure, and growing demands
to increase both the efficiency and the quality of services. Reacting to these challenges, healthcare
enterprises increasingly rely on Information Technology (IT) solutions. In digital imaging departments,
typical IT environments consist of various application systems: hospital information systems (HIS),
radiology information systems (RIS), picture archiving and communication systems (PACS) and imaging
modalities. Historically, these systems have been designed and developed by different communities, and
are typically implemented and installed by different vendors.

WORKFLOW IN RADIOLOGY

Radiological processes consist of numerous well-defined activities which are performed by different
people or systems, in different locations and at different points in time. In a digital department, most of
these activities are supported by computerized application systems and appropriate software
components within these systems

PACS Systems (picture archiving and communication system) are a medical imaging technology which
provides economical storage, retrieval, management, distribution and presentation of medical images.
Electronic images and reports are transmitted digitally via PACS systems. This eliminates the need to
manually file, retrieve, or transport film jackets. It allows a healthcare organization (such as a hospital)
to capture, store, view and share all types of images both internally and externally.

The universal format for PACS image storage and transfer is DICOM (Digital Imaging and
Communications in Medicine). DICOM permits PACSs, Radiology Information Systems (RIS) and more
medical imaging systems to connect with and pass data to systems at other healthcare facilities. Most
PACSs handle images from various medicalimaging instruments, including ultrasound (US), magnetic
resonance (MR), nuclear medicine imaging, positron emission tomography (PET), computed tomography
(CT), endoscopy (ES), mammograms (MG), digital radiography (DR), computed radiography (CR),
histopathology, ophthalmology, etc. Additional types of image formats are always being added. Clinical
areas beyond radiology such as cardiology, oncology, orthopedics, and even the laboratory are creating
medical images that can be incorporated into PACS.
It consists of four major components:

1. The imaging modalities

2. A secured network for the transmission of patient information;

3. Workstations for interpreting and reviewing images;

4. And archives for the storage and retrieval of images and reports.

Combined with available and emerging web technology, PACS has the ability to deliver timely and
efficient access to images, interpretations and related data. It breaks down the physical and time
barriers associated with traditional film-based image retrieval, distribution, and display.

GENERIC PACS WORKFLOW

1. Changes in the order entry are on the horizon, but for now, the order-entry process is the same as in
film-based departments. The technologist needs a requisition to verify the patient ID and to take a
patient history.

2. The order is input into the Radiology Information System (RIS), and the RIS sends a message to the
PACS to find all historic images and put them on the short-term archive. This eliminates waiting for the
file room to retrieve a film jacket from the off-site storage location.

3. The technologist prepares the room, retrieves the patient, and performs the patient history. The
history is recorded on the paper requisition or input electronically into the patient’s computerized
medical record.

4. The technologist performs the examination, and depending on the type of image acquisition device,
the images are processed and repeated as necessary and sent to the appropriate PACS device. The
patient images have been tagged with information from the RIS so that historic image reports are
available at the PACS when the new images are sent. If the patient’s physician does not have access to
the electronic images, a compact disk (CD) or digital versatile disk (DVD) can be made that contains the
images in digital format

5. The requisition is either taken to the radiologist, or the radiologist may pull the images from an
electronic work list. The radiologist also pulls up historic images and reports and compares the previous
images with the current images.

6. The radiologist dictates a report and has it transcribed, or voice recognition software may be used. If
the radiologist uses voice recognition software, he or she can review the report right after dictation,
make corrections, and sign the report, making it final.

=====================================

Key steps Radiology Workflow and its Analysis

Why Workflows are the Core of Radiology

Radiology departments are facing several challenges – increased volume of examinations, cross-site
collaboration, rising costs, and data protection. How can the highest possible efficiency be achieved in
this specialty and how can workflow and IT systems be optimized for maximum productivity?

Key Points:

 Radiology departments can benefit from cost and time-efficient radiology management.
 The key to increased efficiency lies in the workflow and in IT systems that manage these
workflows effectively.
 The goal should always be to digitize and streamline the entire patient workflow from start to
finish.
 Radiology IT systems produce a multitude of data. With intelligent software solutions, this data
can be processed to valid facts that serve as a basis for day-to-day management decisions.

Radiology typically is the medical specialty with the highest investments. At the same time, it offers the
highest potential for optimization and thus savings. The volume of examinations is rising steadily, new
legal requirements (e.g. patient data protection) coming up frequently, and structures are becoming
more and more complex. Cross-site work, working from home, teleradiology, closer cooperation with
referring physicians and other medical departments are constantly presenting radiology with new
challenges.

Therefore, not only the radiology department itself but the entire hospital or entity benefits from a cost
and time efficient radiology management. More patients can be examined, diagnoses are available
faster, treatments can begin earlier. The result is better healthcare for the patients plus investments pay
off more quickly.

But how to achieve the highest possible efficiency? The key to this lies in the workflow and in IT systems
that manage these workflows effectively. While radiology processes differ significantly from those in
other medical departments, radiology has many processes that always run in the same manner.
Solutions specifically designed for radiology that are consistently geared to the workflow offer enormous
potential for optimizing speed, efficiency, and cost-effectiveness.

Modern IT systems dedicated to workflow management consider and streamline workflow aspects in
every process step, trigger mechanisms to start the next process step (e.g. report release or preliminary
release or second opinion) and also provide answers for handling workflow interruptions efficiently that
occur in daily business.

==============================

Integrating the Healthcare Enterprise Workflow Model

From Radiology Workflow to Patient Workflow

Workflow optimization neither starts nor ends in the radiology department. The real workflow starts
with a patient and a physician who decides that imaging diagnostics is needed for this patient. The
examination might occur in one place, but the reporting might be done somewhere else. The patient
workflow does not end when the examination has been carried out and the report is released, but
rather when report (and studies if needed) are made available to the referring physician, the patient and
other physicians involved in the treatment.

As a result, the goal should always be to digitise and streamline the entire patient workflow from start to
finish. Best practices here are integrated, one-stop software solutions: They optimise each workflow
step individually but at the same time avoid process interruptions between systems that may lead to
delays, dual data storage or missing or false information in the next process step.

End-to-End Digital Workflows

Offering patients and physicians the option of making appointments online noticeably reduces the
workload on registration staff - especially if online booking is integrated directly into the appointment
calendar of the radiology information system, thus avoiding work and sensitive data storage in parallel
systems. Cross-site resource planning and standby lists for inpatients are additional factors that ensure
high modality utilization without idle times. In the next step, systems that automatically remind patients
via e-mail or text message of upcoming appoints further help to reduce the no-show rate significantly.

When the patient arrives at the radiology, waiting and turnaround times should be kept to a minimum.
One key factor here is a paperless workflow which at the same time increases quality and thus patient
safety. Paper-based work is slow and error-prone, files can get lost or are not available where they are
needed.

When it comes to reporting, a deep integration of speech recognition into the reporting workflow –
without having to switch back and forth between systems or windows - can boost efficiency to a large
extent. Another important factor for increasing speed, comfort and quality is data availability.
Radiologists can fully concentrate on their task when, after one single click on the examination to be
reported, the corresponding studies show up in the PACS and the correct findings template, patient file,
preliminary findings and case information are available on the screen at a glance. In digitised workflow
systems, all data recorded at previous workflow steps is filled into the report fully automatically. Text
modules can be easily inserted with speech commands, lab or dose values are automatically retrieved
from connected systems and inserted into the report.

A short space of time from examination to reporting is important but, coming back to the idea of a fully
digital patient workflow, needs to be followed by a speedy transmission of findings without media
breaks. Only then is the data immediately available for further treatment - whether in the connected HIS
or a web portal with notifications and access for physicians and patients alike. To ensure a smooth
process, automated workflows must exist for different scenarios, which the radiologist can start at the
push of a button, such as: How can second opinions on the findings be obtained? When and to whom
are preliminary findings transmitted? How to ensure that critical findings reach the referring physician as
soon as possible and can easily be recognized as such?

Finally, a highly automated billing process can help to minimize billing losses. Effective approaches
include pre-defined workflows for all types of insurance models; examination-specific query assistants
registering materials used early on during the examination; automatic import of material and billing
catalogues; automatic checks of billing rules enable a largely automated billing and digital transmission
of services and billing data to HIS or other billing systems.

Workflow-Based Business Management

Through its workflows, radiology IT systems produce a multitude of data. With intelligent software
solutions, this data can be processed to valid facts that serve as a basis for day-to-day management
decisions that the profitability and success of a radiological institution depend upon. Via statistical
analysis and real-time dashboards, problems and workflow insufficiencies can be identified, trends can
be recognized, and management measures can be derived in a timely manner. Cross-site room
utilization, resources and reporting worklists can be directly influenced and managed whenever needed
to achieve the best results.

Stability, Interoperability and Security

Like in all IT infrastructures, workflow management systems can only play to their strengths if they come
along with high stability, reliability, and system availability. Standardized interfaces to PACS, HIS and
further systems guarantee speed and interoperability even in complex landscapes.

In addition, healthcare IT Systems require the highest standards of data security and privacy. This is
especially important since more and more web applications have become a substantial part of
healthcare workflows. One of the central tools are the security guidelines of the Open Web Application
Security Project (OWASP), which assess the most common threats and provide effective measures for
protection against these threats. Additional security is provided by solutions with certified third-party
penetration tests and ISO 27001 information security management certification.

Disclosure of conflict of interest: Point-of-View articles are the sole opinion of the author(s) and they are
part of the HealthManagement.org Corporate Engagement or Educational Community Programme.

HL7 and DICOM standards

Transmission of images and reports between different medical institutes is a hard mission for two
reasons: first, information systems utilize various machine platforms, and second, the medical images
and information are created from different imaging modalities by distinctive producers.

With the growing medical standards, Health Level 7 (HL7) and DICOM, incorporation of heterogeneous,
different restorative images and information into a composed system is made feasible. Interfacing two
medical systems requires two elements: a normal data format and a correspondence protocol. HL7 is a
standard text-based information format, and DICOM incorporates data format and correspondence
protocols. In compliance with the HL7 standard, DICOM is conceivable to exchange medicinal
information such as HIS, RIS and PACS. By adjusting the DICOM standard, the medical images created
from an assortment of modalities and manufacturers might be interfaced as an incorporated health care
system.
HL7, introduced in March 1987, was sorted out by a client–vendor board to create a standard for
electronic information trade in health care environments, particularly for hospital provisions. HL7
standard alludes to the highest level, the provision level, in the seven communication levels of Open
Systems Interconnection (OSI). The main objective is to improve the interface execution between PC
provisions from different manufacturers. This standard confirms exchanging data among health care
systems, for example, HIS, RIS and PACS. On the other hand, DICOM is a significant standard which has
been developed as a consequence of the starting exertions by ACR and NEMA joint council shaped in
1993 to push correspondence of computerized image data regardless of gadget producer. This standard
encourages the advancement and development of PACS to interface with different systems of healing
center data in a similar way. In addition, DICOM permits the making of indicative databases that could
be cross-examined by a wide assortment of gadgets conveyed geologically.
Genetic Workflow in Radiology and PACS workflow

Radiology is changing rapidly. In the healthcare system – and in radiology as an integral part of it – we
are facing a challenging situation of shrinking budgets, increasing cost pressure, and growing demands
to increase both the efficiency and the quality of services. Reacting to these challenges, healthcare
enterprises increasingly rely on Information Technology (IT) solutions. In digital imaging departments,
typical IT environments consist of various application systems: hospital information systems (HIS),
radiology information systems (RIS), picture archiving and communication systems (PACS) and imaging
modalities. Historically, these systems have been designed and developed by different communities, and
are typically implemented and installed by different vendors.

WORKFLOW IN RADIOLOGY

Radiological processes consist of numerous well-defined activities which are performed by different
people or systems, in different locations and at different points in time. In a digital department, most of
these activities are supported by computerized application systems and appropriate software
components within these systems

PACS Systems (picture archiving and communication system) are a medical imaging technology which
provides economical storage, retrieval, management, distribution and presentation of medical images.
Electronic images and reports are transmitted digitally via PACS systems. This eliminates the need to
manually file, retrieve, or transport film jackets. It allows a healthcare organization (such as a hospital)
to capture, store, view and share all types of images both internally and externally.

The universal format for PACS image storage and transfer is DICOM (Digital Imaging and
Communications in Medicine). DICOM permits PACSs, Radiology Information Systems (RIS) and more
medical imaging systems to connect with and pass data to systems at other healthcare facilities. Most
PACSs handle images from various medicalimaging instruments, including ultrasound (US), magnetic
resonance (MR), nuclear medicine imaging, positron emission tomography (PET), computed tomography
(CT), endoscopy (ES), mammograms (MG), digital radiography (DR), computed radiography (CR),
histopathology, ophthalmology, etc. Additional types of image formats are always being added. Clinical
areas beyond radiology such as cardiology, oncology, orthopedics, and even the laboratory are creating
medical images that can be incorporated into PACS.

It consists of four major components:

1. The imaging modalities

2. A secured network for the transmission of patient information;

3. Workstations for interpreting and reviewing images;

4. And archives for the storage and retrieval of images and reports.

Combined with available and emerging web technology, PACS has the ability to deliver timely and
efficient access to images, interpretations and related data. It breaks down the physical and time
barriers associated with traditional film-based image retrieval, distribution, and display.

GENERIC PACS WORKFLOW

1. Changes in the order entry are on the horizon, but for now, the order-entry process is the same as in
film-based departments. The technologist needs a requisition to verify the patient ID and to take a
patient history.

2. The order is input into the Radiology Information System (RIS), and the RIS sends a message to the
PACS to find all historic images and put them on the short-term archive. This eliminates waiting for the
file room to retrieve a film jacket from the off-site storage location.

3. The technologist prepares the room, retrieves the patient, and performs the patient history. The
history is recorded on the paper requisition or input electronically into the patient’s computerized
medical record.

4. The technologist performs the examination, and depending on the type of image acquisition device,
the images are processed and repeated as necessary and sent to the appropriate PACS device. The
patient images have been tagged with information from the RIS so that historic image reports are
available at the PACS when the new images are sent. If the patient’s physician does not have access to
the electronic images, a compact disk (CD) or digital versatile disk (DVD) can be made that contains the
images in digital format

5. The requisition is either taken to the radiologist, or the radiologist may pull the images from an
electronic work list. The radiologist also pulls up historic images and reports and compares the previous
images with the current images.

6. The radiologist dictates a report and has it transcribed, or voice recognition software may be used. If
the radiologist uses voice recognition software, he or she can review the report right after dictation,
make corrections, and sign the report, making it final.