Download Implementing an HIS Imaging Based Workflow in a Non Imaging

SIIM 2016 Scientific Session
Enterprise Imaging
Friday, July 18:00 am – 9:30 am
Implementing an HIS Imaging Based Workflow in a Non Imaging Department
Eric M. Schwieterman, Cincinnati Children's Hospital Medical Center (Presenter); Amanda L.
Golsch, RT(R)(MR), MBA; Emily J. Chesnut, MSE; Shanti Smith, RN; Timothy O’Connor, MBA, CIIP;
Larry J. Jacobson, MSE
Background
As a teaching hospital, we are continually investigating ways to better integrate existing and new
technologies to improve outcomes for our patients. This often leads to opportunities for specialties to
integrate methods and workflows with other areas of patient care delivery. A core technology facilitating
these emerging relationships is the implementation of an Enterprise Imaging Archive (EA; Merge Healthcare;
Chicago, IL) alongside of the traditional Radiology and Cardiology picture archiving and communications
systems (PACS; Merge Healthcare; Chicago, IL). This integration provides the health care enterprise with
means to store diverse types of medical imaging outside of traditional imaging specialties.
The principal challenge to this new integration is developing workflows to meet the specific needs of
departments without traditional imaging programs. The first successful implementation of this method was
in Anesthesia where we created a workflow to help capture ultrasound guided nerve block procedures. This
was chosen as the first implementation primarily for two specific reasons; first, the use case was a billable
order based workflow and, second, DICOM based imaging modalities were being used. This allowed us to
focus on the core workflow and integration with hospital information system (HIS; Epic; Verona, WI) and EA.
The purpose of this writing is to describe how we implemented an automated workflow solution for
anesthesia imaging.
Case Presentation
The first step in this development was engaging key subject matter experts from Anesthesia, Radiology
Informatics, and Information Services (ancillary applications, and electronic medical record builders). The
initial meetings of this group focused on developing the intended use case and gathering the workflow
requirements. This discussion produced three key requirements that would shape specifications of the
project moving forward: 1) the procedures should be ordered at the time of the procedure; 2)
anesthesiologists should be able to work autonomously and complete their work entirely within the patient
context in the anesthesia module within the HIS; 3) all imaging studies should be associated with the
procedure within the HIS.
With our specifications determined we could then commence on the integration design. Very early on it was
apparent that the institution’s HIS method of image linking, use of DICOM modality worklists, and ordering
for Radiology/Cardiology based procedures would have to be modified to be invisible to the Anesthesia staff.
This presented a unique challenge particularly with orders and reporting as Anesthesia uses an operating
room based HIS implementation and produces unique encounters for its work and record entry as compared
to the appointment-based Radiology HIS implementation. To solve this challenge, we integrated the
Radiology and Anesthesia modules so that orders were silently scheduled based on button clicks in the
Anesthesia workflow. A new procedural imaging order type was built and is invisible to the user to facilitate
the inter-module orders required for Anesthesia.
The orders are initialized by a button click within the Anesthesia module and automatically placed in an
“Exam Begun” status bypassing traditional preliminary questions for a similar order in an appointment-based
workflow. After initialized, a custom form is invoked to solicit information about the order type including
anatomical site, nerve block procedure type, and operating room location. This information is then
structured in a print group to form the report context for the imaging record along with the hyperlink to the
images in a similar way to Radiology HIS integrations. Rather than being located on the imaging tab within
the HIS, this print group and link were placed in the “Procedures” and “Notes” section of the HIS were
Anesthesia records traditionally reside. An HL7 message filter prevents the order from being sent to the
voice dictation system as all procedure details are recorded in the HIS.
Another unique challenge of the integration is the elimination of concurrent and end exam workflows
traditionally used in appointment based procedures allowing the Anesthesiologist to focus on the patient
and interact with other staff performing the procedure. This workflow design essentially automates the
patient selection, end exam, and reporting requirements used in Radiology/Cardiology workflows. After the
order is silently scheduled, it appears on the ultrasound machine’s DICOM modality worklist. The
anesthesiologist selects the patient on the modality ensuring correct demographic information. After the
procedure is performed, a DICOM modality performed procedure step (MPPS) message is sent from the
modality to the HIS to bring the order to “Exam Final” status in the patient record. The images are sent to
the PACS and subsequently archived to the enterprise archive server for long-term storage automatically. A
continually running script on the PACS generates an HTTP protocol message to automatically place the study
in “Final” status to ensure that the study does not appear on the radiologist’s reading worklist.
Outcome
Since going live with the integration in November, 2015, the Anesthesia department has performed 349
procedures using this technique to date and produced tangible returns of investment. In addition to being
able to begin billing for this image-guided procedure, we believe that the process designed allows us to
maintain an accurate patient record with fewer steps than the previous manual solution. The placement of
the procedure reports within the electronic medical record allows all users to find the documentation for the
procedure in its expected context within the electronic medical record.
Discussion
Imaging-based workflows performed outside of traditional DICOM-based imaging departments are becoming
more frequent and provides a value added initiative for healthcare delivery organizations developing
Meaningful Use Stage II and III practices. This is perhaps most common with ultrasound as point-of care
ultrasound and procedure-based ultrasound are becoming the standard of care. We believe that efficient
workflows must be developed in order to allow providers to easily perform these procedures while at the
same time following good IT practices. Thus, as we developed this workflow, we employed principles that
would be scalable to other departments. We are now using this model in our ongoing implementation
projects and future planning for our clinical imaging technology needs with specialties including, but not
limited to Rheumatology, Dermatology, Endoscopy, Orthopedic Surgery, and Neurology.
Conclusion
The integration and design of technology utilizing a combination of the Anesthesia and Radiology modules
with the HIS provides the Anesthesia Staff with a mechanism to minimally interact with the technology and
perform the work. Because many of the workflow steps are automated, anesthesiologists are able to
perform ultrasound based procedures with automated patient demographics, automated electronic storage
of images, and automated construction of an imaging-based report that is filed in the typical anesthesiabased encounter within the HIS and linked with the images in the EA. These integrations facilitate greatly
reduced error in documentation and delivery of patient care, as well as, providing additional technical and
professional revenues for the enterprise.
Keywords
Enterprise Archive EA Vendor Neutral Archive VNA, Picture Archiving Communications System PACS, Hospital
Information System HIS Electronic Medical Record EMR, Anesthesia Ultrasound Imaging, DICOM Based
Workflow