“Great case, next case.”
—Private practice radiologists’ mantra
“Faster, better, cheaper...”
—Business paradigm
Radiologists are under pressure to add more value to medical imaging—to provide more
educated, accurate, useful, and efficient interpretations in the face of increasingly
large and complex imaging studies and to communicate this information quickly and
in the most useful manner. The radiology department and radiologist both need to be
better, faster, and cheaper.
Medical imaging informatics (MII) includes many of the processes radiologists need
to reach these goals. MII is the development, application, and assessment of information
technology (IT) for clinical medical imaging. It includes the interfaces of IT and
people.1–3 In practical terms, MII already occurs at a basic level throughout radiology
practice, from the moment a clinician considers ordering an imaging study, until images
and interpretation are used to plan the patient’s treatment.
MII is not an academic exercise. Every radiologist should appreciate its basics. Radiologists
do not need to write computer code, but their lives will be better if they comprehend
MII benefits, products, and processes and how to implement and integrate these systems
at visionary and managerial levels.
Picture archiving and communication systems (PACS) and Radiology information systems
(RIS) are the most visible parts, but MII is more than that. Radiologists were intimately
involved in PACS and RIS throughout their evolution. Now, as basic PACS/RIS become
commodities in radiology practices, radiologists may lose their informatics focus.
They delegate it to the IT department, radiology administrator, or certified imaging
informatics professional (CIIP). To deal with the current workload, and to maintain
income, radiologists often feel driven solely to interpret imaging studies. They keep
their eyes on images and dictate; anything that detracts from that pattern they delegate.
As in many fields, radiologists are expected to know exponentially more about new
imaging techniques, findings, and clinical applications. Why, then, should they learn
about MII, a potentially large and complex field that is not applicable to one’s interpretation
skills, and at first glimpse, does not tie directly to patient care or revenue production?
Our private practice radiology group works at disparate sites that encompass multiple
PACS, dictation systems, and RISs. Qualitative observation of these various situations
suggest between 25 and 100% difference in radiologist efficiency between the best
and worst of our combinations. Even between two sites with supposedly the most efficient,
mainline PACS, radiologist efficiency varies perceptibly. Why?
Causes for this are hard to quantify. In one setting, radiologists with MII knowledge
participated in PACS from the start, through design, RFP, implementation, and continued
oversight. In the second setting, the hospital corporation and its IT department drove
MII decisions and implementation. The second setting’s IT department is fine, and
their PACS vendor is excellent. Both systems run well, are reliable, and on the surface,
provide “a state-of-the-art, filmless, radiology department.” Radiologists are most
efficient, however, at the hospital with an involved, designated, MII radiologist.
Eliot Siegel, MD of the VA Maryland Health Care System gives a well-received talk
on the tsunami wave of increasing radiology work crashing over radiologists.4 His
talk contains a movie clip of Lucille Ball on the chocolate factory assembly line
and her travails as chocolates on a conveyor belt rush by ever more rapidly. This
analogy is painfully apt for radiologists, with their eyes on images, dictation mike
in hand, who race to interpret thousands of images in time to get home for dinner.
What follows is an unabashedly radiologist-centric examination of the radiologist
on the assembly line and examples of how MII can improve a radiologist’s life.
In a simplified model of the radiology assembly line, one may define the patient and
information about him as the “entire patient entity” (EPE) that moves through the
radiology department. Stations on the radiology assembly line, upstream from the radiologist,
perform functions on the EPE, such as add demographic information and history, place
an IV, scan the patient, post-process images, and attach relevant priors. The patient’s
images and clinical information eventually arrive at the radiologist station on the
assembly line. The radiologist’s responsibility is to synthesize all available information
in the EPE and translate it into a clinically relevant written interpretation that,
combined with relevant images, helps the treating physician decide what to do next.
This interpretation is just another (albeit important) process performed on the EPE.
Then, the patient and his image information, now with a report attached, move on down
the line—the report distributed as needed, and the patient to the appropriate treatment.
Like Lucy in the chocolate factory, the radiology assembly line is increasingly demanding
and in need of improvement. One established approach to improve an assembly line is
to decrease by even a tiny amount the time it takes to perform an individual step.5
If that step repeats often, the total time saving is significant. In a simplified
example, for a radiologist who reads a two-view chest radiograph every 2 min, cutting
out 12 s per case means that during a 10-h day, the radiologist either earns 10% more
or gets home an hour earlier.
Done correctly, MII can cut tiny time fragments from every facet of the radiologist’s
tasks. The key concept, however, is “done correctly”. This is critical. What a radiologist
does can be described simply, but beneath that description is a rich, deep set of
knowledge, habits and processes every radiologist uses to perform the practice of
radiology. Nobody except the radiologist will appreciate MII’s subtleties that will
cut minor time increments from each task the radiologist performs for every case.
If radiologists delegate decisions on planning, vendor selection, and implementation
of MII components and systems, the result may be good for many things, but it will
not optimize radiologists’ efficiency. A current example of nonradiologist-centric
MII is voice recognition (VR) dictation of the radiology report. Errors in original
project planning, vendor selection, or implementation of VR can make radiologists
up to 25% less efficient.6–8 On this issue, one hospital administrator facing a group
of frustrated radiologists declared, “...but VR only adds a minute or two of radiologist
time to each case.” Only the radiologist has enough at stake to refocus MII onto radiologist
efficiency.
Four issues illustrate how an II radiologist can improve every radiologist’s experience
on the assembly line. First, how should the EPE be processed before it arrives at
the radiologist station, or phrased differently, what should already be attached and
what steps performed before the imaging study arrives for the radiologist’s interpretation?
Second, what tools does the radiologist need to maximize the time spent to get all
possible information from the images or “quality eyes-on-images time?” Third, what
tools and process allow the radiologist to synthesize efficiently and robustly the
images, clinical data, and his medical knowledge database into a cohesive, accurate,
helpful interpretation? Finally, what should be the report format as the EPE leaves
the radiologist station, to enhance fast, correct, and efficient patient treatment?
IN WHAT STATE SHOULD THE EPE ARRIVE AT THE RADIOLOGIST STATION?
What should occur before “the study” is presented to the radiologist? The radiologist
needs (a) history, including chief complaint, pertinent past medical history, and
relevant laboratory and pathology results;9,10 (b) the current study in a state ready
for interpretation. This assumes radiology technologists obtained the correct images,
preprocessed and labeled them, and put them in the proper presentation state in PACS;
and (c) relevant prior studies with reports.
First, the II radiologist should ensure that all of these data are available to the
radiologist. Second, the II radiologist wants to cut tiny (or often large) amounts
of time from each step the radiologist performs to get this information. Questions
the II radiologist might ask include: How does the radiologist currently get clinical
information? Can radiologist workflow change to best use existing software? If useful
data are on separate enterprise IT databases, can they integrate with the radiologist
workstation so the data are immediately available in a manner that helps the radiologist?
Are the data in an electronic medical record (EMR), and if so, how does the EMR integrate
into the physician workstation in the best way possible for the radiologist? For all
current hospital informatics software, the II radiologist should check a list of that
entire program’s capacities. A familiar system may have helpful features that are
not turned on or implemented because nobody else saw their value. One example is that
the hospital information system (HIS) may have a physician index module, with fields
for physician contact numbers, fax, and even pager and cell phone information, which
might be accessible in a way that makes it easier to communicate with clinicians.
Every piece of information delivered correctly and automatically to the radiologist
is radiologist time saved.
If an enterprise plans to buy a new EMR, HIS, or RIS, the II radiologist should evaluate
it with the thought, “How does this make the radiologist better, faster, and more
efficient?” Questions the radiologist may ask, from easier to more difficult, include:
Does the process involve excess clicking through screens? Are relevant data easily
accessed? Is everything on a single console, with single login and single screen?
How easily are clinical data corrected or updated? Which integrating the healthcare
enterprise (IHE) criteria does the software meet? Does it have smart capabilities,
such as alerts about allergies, renal disease, prior malignancies, or other radiologist-defined
information? Can the software interact easily and robustly with other systems? Can
it transfer clinical information to the report electronically, either manually or
automatically? Does the system have an application programming interface (API) or
software development toolkit that allow the radiologist to direct someone to write
a program to collect all relevant clinical data into a radiologist-centric data page
that pops up simultaneously with the images, and dump relevant data into the final
report?
WHAT TOOLS DOES THE RADIOLOGIST NEED TO OPTIMIZE QUALITY EYES-ON-IMAGES TIME?
Radiologists appreciate this part of MII because it deals most directly with the images.
If the radiology group already uses PACS, are workstations configured to maximize
radiologist’s productivity? Are useful hanging protocols available? Are search criteria
for relevant priors configured correctly? Are toolbars well organized? Workstation
use is astonishingly idiosyncratic, however. Over time, each radiologist evolves his
or her own distinctive PACS/RIS workflow. Despite these diverging workflow patterns,
it is worthwhile for the II radiologist to review the PACS workstation manual and
tools every 6–12 months. As radiology exam characteristics change or as frustrations
of a particular PACS workflow crystallize, the manual may describe helpful tools or
processes one did not think to learn the first time around. For example, the MR on
which we initially did dynamic temporomandibular joint (TMJ) Magnetic resonance imaging
(MRI) automatically re-sorted images by table location, so a movie of the jaw opening
and closing played correctly on the PACS workstation. The MR was replaced with a new
model lacking that capability. After months bemoaning the inefficient PACS that now
forced us to walk out to the MR monitor to review dynamic images, a partner perusing
the PACS manual found the tool to do this.
The rules that allow digital imaging studies to move between disparate systems are
known as Digital imaging and communication in medicine (DICOM). Even rudimentary DICOM
knowledge allows an II radiologist to identify DICOM issues and solutions that affect
radiologist productivity dramatically. When an imaging exam is transmitted electronically,
DICOM defines information describing that study to be sent first, in the “DICOM header”.
Most PACS vendors allow radiologists to use header information to build hanging protocols,
which cause similar types of exams, such as lumbar spine MRs, always to open on the
workstation in the same manner. Several PACS include in their hanging protocol algorithm
the MR series descriptor, such as, “Sag T1”. When a different MR vendor uses a different
series descriptor such as “T1 Sag”, the hanging protocol may not work. A workaround
is to develop an internal institutional list of approved MR series descriptors for
all MR machines. Thus, any “Sag T1” type sequence on any vendors’ MR is labeled as
such. MR vendors do not appreciate a competitor’s labels on their machine, but it
works for the radiologist.
Radiologists often notice monitor quality variation despite the monitor meeting QA
specifications. If an II radiologist understands monitor issues such as luminance,
contrast, resolution, gray scale, video quality, just noticeable difference (JND),
gamma curve, and look-up-tables (LUT), it is much easier to convince the appropriate
person to fix or replace a monitor.11–13 It is also invaluable when choosing new monitors,
which now come in a bewildering array of size, resolution, luminance, and cost. Their
true specifications often are not the same as advertised. Rudimentary knowledge of
monitor physics, perception basics, and calibration issues allows the radiologist
to begin to separate vendor hype from fact. Keeping current on MII also allows the
radiologist to know, for example, of current research showing that certain consumer
grade (e.g., Dell) monitors are acceptable to read everything, even conventional radiographs—knowledge
that may save thousands of dollars per monitor.14 Advising on monitors for the OR,
ED, and specialty clinics offers an opportunity to improve clinician relations and
demonstrate II skills. Surgeons may like a vendor’s fancy new offering, when something
better may actually be cheaper for them. In these situations, physician-to-physician
discussion has the best chance of success. An important sidepiece to image viewing
quality is the workstation computer’s video card, and often an II radiologist is the
only physician to know this.
Sophisticated evaluation of the radiologist workstation is paramount when assessing
a new PACS. The radiologist’s goal is simple to state: “Does this workstation help
the radiologist to interpret a case, and does it help more than other vendor’s workstations?”
This analysis is not trivial. How a radiologist uses the workstation is much more
complex than what appears at first glance.15–17
Examples of trials a radiologist should personally perform on a prospective new PACS
workstation include: How long does it take the radiologist to label a spine in a manner
that makes it easy to read the study and label in a manner helpful to the spine surgeon?
How long does it take the radiologist to build customized MR hanging protocols, and
how well do they work on studies from different MR vendors? Do series automatically
link and cross-reference in an intuitive, robust, fashion? Finally, despite radiologists’
continued request for fewer mouse clicks, vendors often have surprisingly inefficient
processes for radiologists to complete common tasks. The radiologist is the best person
to assess these subtleties that may plague workflow.
A current hot topic is how to integrate effectively advanced image post-processing
programs such as 3D, CAD, fusion, and functional imaging, particularly as many new
programs are on the horizon.18–24 Effective integration requires critical II radiologist
skills. The II radiologist can be a visionary to identify useful programs and separate
hype from reality.
SYNTHESIS OF IMAGES, CLINICAL DATA, AND KNOWLEDGE DATABASE INTO AN INTERPRETATION
The radiologist synthesizes what he sees on the images, clinical data, and his medical
knowledge to produce the interpretation. This should be a cohesive, accurate, helpful
discussion that adds value to the images.
Presume the EPE arrives at the station in the approved manner (proper test performed
correctly, relevant clinical information easily available), and the workstation is
optimized to see the images. The final piece, the medical knowledge database, is expanding
in the same fashion as study complexity—seemingly too fast to keep up. MII opportunities
to increase the radiologist’s knowledge base are myriad,25–27 and many new options
are in development. The II radiologist can help evaluate which to use and how best
to implement them. For example, since we installed a STATdx (http://www.amirsys.com)
link on all diagnostic workstations in hospitals, clinics, and radiologists’ homes,
radiologists who use it routinely believe they save significant time everyday, by
not having to search for textbooks or articles they need to buttress their own internal
knowledge. They also suggest that their reports have improved through more focused
and complete differential diagnoses and improved recommendations for patient diagnosis
and treatment. Recently, more than one clinician commented on our radiologists’ improved
clinical relevance because recent reports included clinical pearls shamelessly plagiarized
from online information. “Faster, better, cheaper...”.
IMAGE REPORT FORMAT
Once the radiologist finishes the interpretation and generates the report, that should
be defined as the moment the EPE is ready to move to the next station down the assembly
line, and the radiologist is ready to receive the next case.
The report should be in a form such that (a) the station down the line charged with
imaging information distribution can perform that task quickly and correctly, and
(b) it adds significant value to the imaging study and facilitates fast, correct,
and efficient patient treatment. The II radiologist should lead the team charged to
develop the radiology report. The report content may be a combination of the radiologist’s
written interpretation, key images, and references to other images or clinical recommendations.28–30
Here again, the II radiologist plays a pivotal role because of his depth and breadth
of knowledge. The II radiologist is the key person on the team who understands clinical
necessities as well as subtleties of key images, potential IHE initiatives, or tools
within the PACS, RIS, or EMR that allow information-rich report generation.
A station further down the assembly line should distribute the report, rather than
the radiologist. How that station distributes the report is a separate topic. Once
the radiologist’s report is “attached” to the EPE, the radiologist is ready to focus
on the next EPE coming down the line.
SUMMARY
In summary, this paper offers radiologists examples of medical imaging informatics
that may benefit them directly, and suggests the value of an imaging informatics radiologist
to every radiology group.