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SIIM 2016 Scientific Session Enterprise Imaging Friday, July 18:00 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