RadStream offers radiologists automatic prioritization and reporting mechanisms to improve critical results communication.

Mark J. Halsted, MD, chief of research, radiology informatics, Cincinnati Children’s Hospital

When Cincinnati Children’s Hospital first adopted RIS and PACS, the radiologists gained unprecedented access to the files they needed. But while these systems saved radiologists the hassle of rooting through paper stacks to find their cases, it did not solve the problem of prioritization. They still had to drop what they were doing frequently to field phone calls, faxes, and pages from clinicians, physicians, and other concerned parties, who wanted information on a stat case immediately. That meant constant reordering of cases throughout the day, which usually kept radiologists after hours to make up for lost time.

So, Mark J. Halsted, MD, chief of research, radiology informatics at Cincinnati Children’s Hospital, and his team found themselves with two problems to address. “We found that when radiologists had many stat cases built up, there was no way to know which one to read first, and that ultimately slowed down care for everybody,” he said. “So, we wanted to have some way to prioritize cases automatically. We also found that it was a major time burden for radiologists to convey critical results themselves.”

To provide relief to the overwhelmed radiology department on these two counts, Halsted and his team developed their own software application called RadStream, which they launched throughout the hospital in July 2005. The application, since licensed to Boston-based Amicas Inc, incorporates a prioritization algorithm to automatically list cases in order of importance, and it also streamlines the communication process between radiologists and clinicians.

“It’s made such a night and day difference for us—just the base functionality of having cases automatically prioritized and having automatic conveyance of critical results,” he said. “Those things are really kind of the universal thorns in the side for radiologists.”

Streamlined System

RadStream presents worklist views for techs, radiologists, as well as operators and administrators. “Basically, RadStream serves as the RIS replacement,” Halsted said. “It presents all the cases that need to be read, and those worklists are tailored for each radiologist, so it’s actually very simple to see which case you should read next at any given time.”

For each case entered into the system, technicians answer five acuity questions by selecting the appropriate radio button on the screen. These are whether it is a stat case, what the level of subjective acuity is, whether a patient is waiting for the results in the hospital (Cincinnati Children’s policy guarantees results within the hour for these patients), whether the patient or parent is anxious to receive the results, and whether the requesting physician is anxious to receive the results. There are also considerations for the area of the body and the age of the patient.

Based on the answers to these questions, the case is assigned a number. The higher the number, the higher it appears on the radiologist’s worklist. Each case also has a time component that moves it up the list, which means that no case will be aged at the bottom of the stack.

The worklists also can be shared by everyone in the department, if desired, so that no one radiologist is overburdened with cases. “With RadStream, we also have significant workload balancing, meaning that if any one person is really busy, other people can pitch in and take up the slack,” Halsted said. “So, there’s not that desperate sense of being way behind anymore, that we used to have.”

When a radiologist finishes a case, a button click automatically delivers the finished worklist item to an operator, who then calls the referring physician to report the case results. The results are read directly from the radiologist’s notes on the screen. Meanwhile, the radiologist can move on to the next case in the worklist without interruption.

For some cases with abnormal results, radiologists may choose to speak directly with the clinician. In that case, the radiologist presses the appropriate button, and the operator connects the clinician to the radiologist directly.

Clinicians embrace this reporting system as it also saves time on their end. “Both the clinician and the radiologist are generally busy, and to try to get them both free to speak at the same time on the phone is more time-consuming for both parties than it is if the operator can get the information from the radiologist’s report and convey it as soon as the clinician arrives at the phone,” Halsted said.

Having this mechanism in place means that radiologists are less likely to receive urgent calls regarding status updates for priority cases. “What the RadStream triage algorithm does is make sure that the case most likely to interrupt your workflow is the first one you read, and then it makes sure that that report gets pushed out to the clinician,” Halsted said. “Our clinicians have come to trust our workflow so much that they are less likely now to call us asking for results.”

Immediate Improvements

The actual implementation of RadStream was nearly painless, according to Halsted, who said his department was up and running on the software within a week. Of course, there are always some glitches to overcome when it comes to redesigning processes.

“One thing that we did learn putting it in was that nothing shines a spotlight on the vagueness in workflow like automating it,” he said. For example, his team found that staff often tailored their workflow to the preferences of each radiologist rather than using the same system for everyone. “When you try to automate or code human behavior, you usually find that human behavior has some gray zones that you didn’t realize existed. We got over that hump very easily,” he said.

Almost immediately, radiologists found that they were getting through their cases in short order. Without having to field phone calls and other interruptions, they gained between 2 and 3 hours per day. To measure these savings, Halsted’s team looked at 26,000 cases prior to RadStream implementation and 29,000 after. “Our median report turnaround time for outpatients decreased by 56%, and our workflow interruptions decreased by 28%,” Halsted said. “Our radiologists were spending so much less time on the phone that across the department we essentially gained two radiologists by cutting down on the interruptions.”

While this time savings means that the department did not need to hire an army to keep up with continually rising volumes, it did not translate to staff cuts either. Instead, the department can now take on more time-consuming cases, such as cardiac MR and fetal MR, and radiologists no longer need to put in the long hours to keep up with their case loads. “I’m sure that we haven’t had to increase our staff as rapidly as we would have without RadStream, and I know that quality of life is much better,” Halsted said. “I think this is a retention tool and a recruiting tool. I know that if you took RadStream away from our staff now, they would mutiny.”

The software has also been a positive change for patients. Halsted’s team circulated 500 patient surveys before and after RadStream was implemented. Not only did RadStream streamline the workflow and communications between radiologists and physicians, but it also improved patient perceptions of the radiology experience, which had shown a slight dip after the department had implemented voice recognition for case dictation.

The reason that voice recognition alone didn’t impress patients was that often cases would sit in the system awaiting final sign-off or communication with the physician. This meant delays in getting those results to the patient. “The promise of voice recognition is that reports that used to be transcribed over hours are now instantly transcribed and available to the referring physician,” Halsted said. “It’s not good enough to have a report that is transcribed sitting on a database somewhere on your system. Unless we actually reached out to the clinician and gave them the results, from the patient’s perspective, it was as though no report was yet generated.”

What made the difference for patients was how much more quickly they received their results after the department introduced RadStream. “Really, what you need to do to complete the radiology communication loop is get the report to the clinician, and that’s what RadStream did,” Halsted said.

Since implementing RadStream, Halsted said the application has never gone down unexpectedly and that it is as robust and reliable as any other commercial software the department uses. In fact, it proved to be invaluable to the department when the facility’s PACS system went down for 24 hours, creating a backlog of cases that needed to be completed the next day along with the team’s regular case load. “We were caught up in a matter of several hours, not several days,” Halsted said. “And we were caught up with not only the day before, but also that current day. It’s because the workflow is so much more efficient.”

He credits this to the shared worklists. “If you have five radiologists reading five independent worklists, and one of them is very busy, that worklist is going to move slowly that day,” he said. “But if the five radiologists share one worklist, the four who aren’t as busy can pick up the slack for the fifth who is busy. As a result, the overall worklist will move faster.”

Future Features

Amicas is incorporating some of its own features into the software and plans to conduct beta testing by the end of the year with the goal to launch in 2008. The Amicas release will integrate fully with a facility’s PACS system—a capability the original version does not have. Facilities can choose to purchase the system with the Amicas PACS system or as a stand-alone version that works with their existing PACS.

Amicas will integrate the prioritization algorithm with the company’s current worklist features and interface. The worklists also will update in real time. “Amicas will be truly integrating the programs so that to go from one case to the next in Amicas RadStream, you’ll just click Next Case, and the next case will load,” Halsted said. “You won’t have to deal with the worklist at all if you don’t want to.”

Every action for a case—from the uploading of images to the radiologist’s sign-off to every attempted communication with the clinician—is logged and time-stamped in the Amicas Vision Watch view. Because RadStream allows documentation of every communication, Halsted describes the software as a good first step toward meeting the 2008 Joint Commission patient safety goals, particularly the requirements for critical results conveyance.

“[The Joint Commission] doesn’t actually require that you document that you do the conveyance, but I think that documenting it is vastly better than just conveying the results, because now you’ve got a permanent record of all these results that were conveyed,” Halsted said. This documentation can help radiology departments head off complaints or even lawsuits related to communication of results by showing proof of who was contacted when.

While Amicas performs the next phases of its development, Halsted’s work on RadStream is far from over. “We have not rested on our heels since licensing this to Amicas,” he said. “We continue to improve it and look for additional software tools that we can build and modularize that can interact with RadStream and further improve workflow.”

Halsted sees the software as an early step toward improving patient care by streamlining processes within health care. “I think we’re still early in recognizing the importance of workflow to improving patient safety throughout health care and to reducing costs throughout health care,” he said. “It’s a very exciting time.”

Ann H. Carlson is a contributing writer for Axis Imaging News. For more information, contact .