radiology and epr at the brighton radiology visit

Homerton University Hospital NHS Foundation Trust

Radiology and EPR Radiology and EPR at the Brighton Radiology at the Brighton Radiology

VisitVisit

• Anant PatelAnant Patel• Lead Radiographer Lead Radiographer

(CG/RPS/IT/Redesi(CG/RPS/IT/Redesign)gn)

• Mohmed PatelMohmed Patel• PACS ManagerPACS Manager


Brighton ObjectivesBrighton Objectives

• Visit EPR site with radiology integration Visit EPR site with radiology integration (Anant)(Anant)

• Radiology Information System Radiology Information System (RIS)/PACS & Desk Top Integration (RIS)/PACS & Desk Top Integration (Mohmed)(Mohmed)

• Applications integrated to RIS Applications integrated to RIS (Mohmed/Anant)(Mohmed/Anant)

• Q & As (Anant/Mohmed)Q & As (Anant/Mohmed)• ? Anything else (Brighton contingent)? Anything else (Brighton contingent)


EPR at HUHEPR at HUH

• Radiology paperless (Sept 2004) Radiology paperless (Sept 2004) with 2 exceptionswith 2 exceptions1. Labels (contents)- act as request form1. Labels (contents)- act as request form

2. External referrals' (GPs/Mental Health) 2. External referrals' (GPs/Mental Health) paper requestspaper requests

• Radiology film-less (PACS April Radiology film-less (PACS April 2007)2007)

• Desk Top Integration (2010)Desk Top Integration (2010)


ContentsContents

• Radiology involvement with Radiology involvement with Homerton/Newham ProgrammeHomerton/Newham Programme

• Future FlowsFuture Flows• IssuesIssues• Other applications it’s Other applications it’s

integrated/interfaced withintegrated/interfaced with• The GoodThe Good


My Involvement with My Involvement with HUH EPRHUH EPR

• Involved with procurement (1999-2003)Involved with procurement (1999-2003)• Radiology System Designer for Homerton Radiology System Designer for Homerton

and Newham (2003-2004)and Newham (2003-2004)– RedesignRedesign– Design decisionsDesign decisions– Additional hardware and software requirementsAdditional hardware and software requirements

• Training (2004)Training (2004)• Go Live then troubleshooting (2004-2005)Go Live then troubleshooting (2004-2005)• Radiology EPR (2008-)Radiology EPR (2008-)


Why Cerner?Why Cerner?• CernerCerner only one with a high level of integration (no only one with a high level of integration (no

maternity though)maternity though)• McKessonMcKesson (Bangkok) only had a few modules that (Bangkok) only had a few modules that

were integrated (Pharmacy/Radiology) with RIS/PACS were integrated (Pharmacy/Radiology) with RIS/PACS (Toulouse)(Toulouse)

• Siemens no real live system (Sweden), though Siemens no real live system (Sweden), though RIS/PACS at WorcesterRIS/PACS at Worcester

• System CSystem C (Liverpool) too many interfaces and little (Liverpool) too many interfaces and little confidence after demosconfidence after demos

• CernerCerner very good at selling from demos, to site visits very good at selling from demos, to site visits (Detroit) to HQ environment (Kansas)(Detroit) to HQ environment (Kansas)

• Cerner Cerner also able to demo majority of requirements on also able to demo majority of requirements on a live system even if we didn’t understand them fullya live system even if we didn’t understand them fully


Once Contract Signed..Once Contract Signed..

• Current flowsCurrent flows• Design Consultancy SessionsDesign Consultancy Sessions• QuestionnaireQuestionnaire• Future FlowsFuture Flows• Making the design decisionsMaking the design decisions


Current FlowsCurrent Flows

• Mapped paper flowsMapped paper flows– From requesting to results going to From requesting to results going to

consultant in boxesconsultant in boxes

• Needed stronger radiology voice Needed stronger radiology voice regarding IRMERregarding IRMER– Open requesting policyOpen requesting policy


Design Consultancy Design Consultancy SessionsSessions

• Sessions organised by Cerner to Sessions organised by Cerner to demo the solution to the system demo the solution to the system designersdesigners

• Questionnaire provided to draw up Questionnaire provided to draw up future flowsfuture flows

• This is your clinical contract with This is your clinical contract with supplier!supplier!


Questionnaire ContentsQuestionnaire Contents

• Order processing (Powerchart etc)Order processing (Powerchart etc)• Order Entry FormatsOrder Entry Formats• Patient LabelsPatient Labels• Cancel examsCancel exams• Radiographer infoRadiographer info• Radiology ReportRadiology Report• Additional InformationAdditional Information


Future Radiology Patient Future Radiology Patient FlowsFlows

– Four flows• Paper GP requests direct access (XR)- Paper GP requests direct access (XR)-

Department Order EntryDepartment Order Entry• Paper GP requests schedulable (US)- Paper GP requests schedulable (US)- PM PM

OfficeOffice• Direct EPR Referrals (XR, emergency CT, Direct EPR Referrals (XR, emergency CT,

Mobiles etc)- Mobiles etc)- Powerchart/FirstnetPowerchart/Firstnet• Schedulable requests (CT, MR, US etc)- Schedulable requests (CT, MR, US etc)-

SchedulingScheduling


GP/MH Paper Referral

(X-Ray)- Dept Order Entry

Internal Electronic Referral(X-Ray)-

Powerchart/Firstnet

Paper form is brought to desk

and entered onto Dept Order

Order is made via PowerChart in O/P

Clinic

Clinical details checked/previous reports and exam started by Radiographer- Rad On Line Wklist (EPR)

Report is dictated by Radiologist with Voice Recognition RDT

GP/MH Report printed and sent electronically

Internal report goes into PowerChart/Firstnet/PACS

Report is signed out by Reporting Radiologist/Radiographer/Sonographer via RDT

GP/MH Paper Referral

(e.g. US)- PM Office

Internal Referral(US, CT, MRI)-

Powerchart/Firstnet

Add patient to Radiology Wait List- PM Office

Reception staff prioritise the

referral on wait list- PM Office

Schedule Patient from Wait list (Person who vetted is entered as Ordering Physician)-

Scheduling

Requests the exam as part of Scheduling,

changes Rad Request to the priority assigned

Urgent/Routine

Radiologist vets referral form and assigns priority- Paper Request

Request list is pulled from Scheduling

enquiry by reception staff

Schedule patients as Routine booking in

Appointment Book

Confirm appointment and

give appt. letter to Radiologist to vet.Vetting done via

Rad online worklist(EPR)

Check in Patient and Modify

Encounter at Reception- Scheduling

RadiographerChecks out Patient if

scheduled- Scheduling

Vetting done via RDT Vetted by is ticked and

Priority is changed from Rad request

Lettersent to Patient

Rad completes exam from Modality Worklist (DMWL)

Rad completes exam from Rad On Line Wklist (EPR)

Reading Radiologist set on PACS

Contents Label Printed at nearest label printerLetter

sent to Patient

Radiologist/Rep Radiographer uses PACS Reporting Wklist which is bridged with EPR

PAPER REQUEST FROM GP OR

OTHER EXTERNAL REFERRER- SCHEDULED

PAPER REFERRAL FROM GP OR OTHER

EXTERNAL REFERRER- DIRECT ACCESS

ELECTRONIC REFERRAL –

DIRECT ACCESS

ELECTRONIC REFERRAL – SCHEDULED


GP (Paper) Flow- A&CGP (Paper) Flow- A&C

• Paper details copied to EPR OrdercommsPaper details copied to EPR Ordercomms– Not scanned, as could be easier for codingNot scanned, as could be easier for coding

• Appointments added to electronic wait Appointments added to electronic wait listlist– A&C initially scheduleA&C initially schedule– Vetted/justified and Vetted/justified and

rescheduled/cancelled/changed if necessaryrescheduled/cancelled/changed if necessary– Letter to patientLetter to patient

• Direct Access entered onto OrdercommsDirect Access entered onto Ordercomms• Exam to RIS worklist for that dayExam to RIS worklist for that day


OP/IP/A&E (Electronic) OP/IP/A&E (Electronic) FlowFlow

• Requested electronically (referrers)Requested electronically (referrers)• Appointments (A&C staff)Appointments (A&C staff)

– Queued then scheduled by A&C staffQueued then scheduled by A&C staff– Vetted/justified by IRMER pracitionersVetted/justified by IRMER pracitioners– OP Letter sent, otherwise IP/A&E OP Letter sent, otherwise IP/A&E

verbally notifiedverbally notified

• Direct Access (non-schedulable) Direct Access (non-schedulable) straight to RIS Worklist for the daystraight to RIS Worklist for the day


Scheduling (Electronic) Scheduling (Electronic) FlowFlow

• Check in (A&C) patient and ensure Check in (A&C) patient and ensure correct encounter selectedcorrect encounter selected– Notification when patients have Notification when patients have

checked in (status changes from Red to checked in (status changes from Red to Yellow)Yellow)

• Check out (Radiographers) patientsCheck out (Radiographers) patients– Notification from Yellow to RedNotification from Yellow to Red

• Correspondence module associated Correspondence module associated to scheduling difficult to change for to scheduling difficult to change for specific exams/modalitiesspecific exams/modalities


Radiographer FlowsRadiographer Flows

• Check previous examsCheck previous exams• Start/complete/vet examStart/complete/vet exam• Add image usage/contrast/dose Add image usage/contrast/dose

information etcinformation etc• Ensure data transferred to PACSEnsure data transferred to PACS


Radiologist FlowsRadiologist Flows

• PACS centric flowPACS centric flow• Use templates or VR to dictateUse templates or VR to dictate• Sign immediatelySign immediately


Future Hardware FlowsFuture Hardware Flows

• PCs at all areas where paper was PCs at all areas where paper was used (viewing areasused (viewing areas

• Label printers for radiology and Label printers for radiology and pathology (biopsy/drainage pathology (biopsy/drainage procedures)procedures)

• Voice recognition/digital dictation Voice recognition/digital dictation hardwarehardware


Other Applications linked Other Applications linked with Radiology (RIS/PACS)with Radiology (RIS/PACS)

• Powerchart (Nurse/Dr Application)Powerchart (Nurse/Dr Application)• Firstnet (A&E dept)Firstnet (A&E dept)• Scheduling (OPD, Radiology, Theatres)Scheduling (OPD, Radiology, Theatres)• PMOffice (PAS)PMOffice (PAS)• Surginet (Theatres- not required)Surginet (Theatres- not required)• Casenote and Film Tracking (?)Casenote and Film Tracking (?)• Winpath (not Pathnet- Pathology)Winpath (not Pathnet- Pathology)• Keystone (electronic reports to GP via Keystone (electronic reports to GP via

interface)interface)• BT/Sectra PACS (via Insignia PACS)BT/Sectra PACS (via Insignia PACS)


PACS-EPRPACS-EPR


Order Entry Format Order Entry Format Design I Design I

• Which fields needed?Which fields needed?• Which fields are mandatory?Which fields are mandatory?• Which fields are mandatory in Powerchart Which fields are mandatory in Powerchart

(electronic requests)?(electronic requests)?• Which fields are mandatory for paper Which fields are mandatory for paper

requests Department Order Entry (DOE) ?requests Department Order Entry (DOE) ?• Which fields are mandatory in PM Office Which fields are mandatory in PM Office

(paper) and Scheduling (electronic)?(paper) and Scheduling (electronic)?• See Synergy Article (Patel and Hogg 2009)See Synergy Article (Patel and Hogg 2009)


Issues I- TechnicalIssues I- Technical

• Support (in house very very limited resources)-Support (in house very very limited resources)-– Non clinicalNon clinical– New services – Mammos 4 years to developNew services – Mammos 4 years to develop– Ca wait data hard to collect from CDSCa wait data hard to collect from CDS– Updating slow- Mental Health/Podiatry referrersUpdating slow- Mental Health/Podiatry referrers– *Recommend similar model to BT helpdesk**Recommend similar model to BT helpdesk*

• Not full integration between Radiology and Not full integration between Radiology and SchedulingScheduling– Fields (consultants don’t carry over)Fields (consultants don’t carry over)– Cancelling scheduled appointments and then the Cancelling scheduled appointments and then the

examexam

• Servers overloadedServers overloaded


Issues II- ClinicalIssues II- Clinical

• IRMER-IRMER-– Workaround having schedulable to orders, i.e. Workaround having schedulable to orders, i.e.

vettingvetting– Non Medical Referrers, Open Requesting PolicyNon Medical Referrers, Open Requesting Policy

• Delays in lack of desk top integration (clinical Delays in lack of desk top integration (clinical risks)risks)

• Encounters (patient episodes)- ZZ SectionEncounters (patient episodes)- ZZ Section• Clinical details (wrap around text)Clinical details (wrap around text)• Obstetric US not integrated (separate system)Obstetric US not integrated (separate system)• More Radiology specific code sets (cancel More Radiology specific code sets (cancel

reasons)reasons)


Issues III- Multiple SitesIssues III- Multiple Sites

• Standardisation of flowsStandardisation of flows– Mostly the sameMostly the same– Workarounds when there are notWorkarounds when there are not

• Newham patients coming across to Newham patients coming across to HomertonHomerton– Requires IT admin communication Requires IT admin communication

between sitesbetween sites


Issues IV- TargetsIssues IV- Targets

• Ca not identified- still manualCa not identified- still manual• Difficult to quickly look at waiting Difficult to quickly look at waiting

times, need an Information reporttimes, need an Information report• Information reports needed to be Information reports needed to be

created by IT not RIS manager and created by IT not RIS manager and dependent on a particular downloaddependent on a particular download

• Current lack of awareness of DSCN Current lack of awareness of DSCN 14/2009 and DSCN 18/200914/2009 and DSCN 18/2009


Issues V- PACS via Issues V- PACS via BrokerBroker

• Messages not always going acrossMessages not always going across– Patient merges is intermittentPatient merges is intermittent– Minimum updates go acrossMinimum updates go across– Messages from DMWL do go acrossMessages from DMWL do go across

• Accession Linking reports not Accession Linking reports not automaticautomatic

• Clinical risks due to lack of DTIClinical risks due to lack of DTI


Issues VI- MiscIssues VI- Misc

• CommunicationCommunication– Need to test every change to the system Need to test every change to the system

even if not directly connected with even if not directly connected with radiology e.g. new isolation field code setradiology e.g. new isolation field code set

– Paper work immense to get a change, Paper work immense to get a change, more than BT PACSmore than BT PACS

• Downtime/ContingenciesDowntime/Contingencies– FullFull– PartialPartial


Additional BenefitsAdditional Benefits

• Incidents- were auditable via Incidents- were auditable via PowerchartPowerchart

• Incidents- picked up via PACSIncidents- picked up via PACS• Privileges for referrers (non Privileges for referrers (non

medical)medical)• Monitor work from any PCMonitor work from any PC


GoodGood

• Couldn’t go back to old systemCouldn’t go back to old system• Couldn’t go back to paper systemCouldn’t go back to paper system• Paperless except labels/consent formsPaperless except labels/consent forms• Messaging goes across to PACS most of the Messaging goes across to PACS most of the

timetime• BT managing PACS, unfortunately not HUH BT managing PACS, unfortunately not HUH

EPREPR• Request ‘forms’ can be vetted from anywhereRequest ‘forms’ can be vetted from anywhere• Most actions auditable via information dept Most actions auditable via information dept

(from requesting, to rebooking)(from requesting, to rebooking)


ReferencesReferences

• Patel, A., and P. Hogg. 2009. CuttPatel, A., and P. Hogg. 2009. Cutting the Paper ing the Paper Chain. Chain. SynergySynergy, September 1, 26-, September 1, 26-30. 30. http://www.proquest.com/ (accesshttp://www.proquest.com/ (accessed November 16, 2010)ed November 16, 2010)

radiology and epr at the brighton radiology visit

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