Ideas in Hospital-Based Imaging

Radiology File Room: Extreme Makeover
The Methodist Hospital Research Institute Focuses on Core Areas of Study

Radiology File Room: Extreme Makeover

Keeping pace with processing a growing load of medical imaging requests on a daily basis is a common challenge for many busy hospitals. Here is how one institution met the challenge with innovative thinking, a focus on electronic image transfer, and employee recruitment and training.

The University of Wisconsin Hospital and Clinics (UWHC) have been utilizing PACS since 1997. Thanks to the leadership of Gary Wendt, MD, we are well ahead of the PACS knowledge curve. Dr Wendt has been the visionary responsible for implementing PACS at UWHC, with a 10-year track record of process improvement and efficiency gains. Our mission is simple: to improve workflow process in order to make the radiologist more efficient and to provide better patient care. This is not unlike many other institutions that buy a PACS and also have goals of reaping cost-saving benefits.

One key improvement has been to partner with surrounding institutions to electronically send images encrypted to our PACS system via a Virtual Private Network (VPN). Over time, the volume of electronic imports along with CD imports equaled the number of hard-copy films being handled. This shift in workflow required personnel to understand the virtual world of image movement. The PACS team, who had been charged with caring for the servers, workstations, and training, was also adding the responsibility of tracking images in the system. This added work was overloading the team and taking away resources that could be used to implement other improvements.

Meanwhile, another group intrinsic to our image management process—respectfully called the “Fileroom”—was being pushed aside. This group had historically been responsible for film jacket management, including handling image requests and tracking in the RIS. The standards of image management were developing at a breakneck pace that was exceeding the technical capabilities of the average file-room employee. As a result, a bottleneck was developing in regard to our ability to process the daily load of medical image requests. We soon discovered that we had neglected this valuable resource. We had not properly trained our file-room personnel and wrongly assumed they would be able to keep up with the changing workflow simply through on-the-job exposure.

Ultimately, this situation resulted in both operational and personnel problems. Our file room was moving more than 1,800 film jackets per day to support our various clinics. Our manpower was fully utilized managing film jackets, and we were now asking them to import an additional 50 CDs and dozens of electronic transmissions per day. The vital piece of electronic image management was to edit and manipulate study information to coincide with UWHC EMR conventions.

At that point, most file-room employees did not even use e-mail, let alone possess the technical capabilities to manipulate images in a PACS. We were getting bogged down, and the employees were becoming overwhelmed. It became obvious that significant changes were needed.

Just as radiologists don’t like comparing hard-copy film and digital images, we quickly saw the advantage of working with only one medium. With the cooperation of several radiologists, department leaders, and PACS personnel, we committed ourselves to a fully digital image management workflow. The first thing we had to do was eliminate our hard-copy movement internally. The plan was called “Safe Dating.” The reason for moving the 1,800+ jackets was to give the radiologists and clinicians the patient’s most recent priors. The “Safe Dating” process included going through each jacket and digitizing all films of each modality back to a predetermined date. The term “Safe Dating” told the doctors everything after the predetermined date was guaranteed to be in PACS. Initially, it required touching all of our film jackets, but once it was done, we would never need to move them again.

The big picture gain meant that we would be providing all 1,000+ UW physicians with instant access to prior images. The patient experience was also improved. Now the patient no longer had to hope the hard-copy jacket followed them through their daily clinic visits. Lost jackets and untimely deliveries were a thing of the past. We ultimately were able to reduce the number of staff needed to move jackets, allowing them to focus on “electronic management” of images. This project proved to be a major win.

Despite this success, however, we continued to have problems with employee turnover. We found that new hires were neither expecting nor prepared for the higher-level technical work associated with PACS, and that our current pay structure was not adequate to keep our trained people. In order to consistently deliver great customer service, we needed to retain employees.

Working with hospital employee labor relations and the employee union, we reclassified the file-room position descriptions (PDs). The new PDs established skill level requirements that both current and new employees needed to meet. The new positions also offered an elevated salary.

One other critical step in this decision was to provide full-time support and training to the file-room staff. We made the decision to utilize one of the FTEs available in the file room to create a new position called an Associate PACS Analyst. This position had the responsibility of bridging PACS innovation with file-room operational needs. The ultimate focus of this position was to condense the high-tech PACS lingo into layman’s terms and to provide the current file-room employees with the technical background and education necessary for them to succeed in their expanded roles. This was accomplished through a variety of training exercises, process documentation, and ongoing competency testing. File-room employees received training in cross-sectional anatomy, PACS, RIS, remote desktop management, and day-to-day image management processes, to name a few.

Over the years, PACS had divided image management into two worlds: digital and hard copy. Our initial thought was that current staff might be threatened by the new requirements, but instead we found that they embraced the challenge. Reconnecting the two areas has provided efficiencies and synergies between people and processes. The end result was the ultimate goal of increased quality patient care.

—Jeff Iverson and Craig Fitzwilliams

Jeff Iverson is enterprise imaging manager and Craig Fitzwilliams is PACS analyst for the University of Wisconsin Hospital and Clinics. Contacts: and

The Methodist Hospital Research Institute Focuses on Core Areas of Study

The Inveon preclinical imaging system from Siemens Medical Solutions allows the Research Institute to conduct trials involving small animals.

To become an academic institution in its own right after its famous split from Baylor College of Medicine in 2004, the Methodist Hospital System, Houston, launched the Methodist Hospital Research Institute to promote the research and teaching programs that such an academic institution requires. The Research Institute will eventually be housed in a 420,000-square-foot facility, scheduled for completion in 2009. In the meantime, research and development is already under way.

“The Research Institute is infrastructure that really supports all of the clinical departments doing research,” said King Li, MD, FRCP, MBA, radiology department chairman for the Methodist Hospital System.

The advantage of having a central research program is that all departments can have access to increased resources. “For example, if you have only a few people in a particular department interested in a certain problem, you can leverage a lot of other expertise that is outside of the department to do the work,” Li said. “It’s also a way of communicating with each other.”

The Research Institute will ultimately have five cores, two of which are already up and running. The first is imaging, which includes all molecular imaging, conventional imaging, image-guided intervention, and ancillary support, such as imaging contrast chemistry and molecular biology. The second core is bioinformatics, which involves everything from clinical informatics to image processing to analysis of complex data sets. The three remaining cores are currently under development: genomics, proteomics, and stem cell research.

As part of the imaging focus, the Research Institute purchased the Inveon preclinical imaging system from Siemens Medical Solutions, Malvern, Pa, which allows it to conduct trials involving small animals. “In order to translate some of the basic science development into clinical practice, part of the steps that are necessary to take include doing experiments in small animals,” said Li, adding that most imaging equipment designed for humans is too large for such trials. “We have basically bought the system that allows us to do CT scans, SPECT imaging, and PET imaging in small animals.”

This investment will further the Research Institute’s focus on cancer research. “We have developed our own imaging contrast agents, for both looking at enzyme activities and also looking at different molecular markers,” Li said. “For example, we have our own patented nano-particle technology for lighting up angiogenic vessels, and, using those molecular imaging tools, we can now find the lesions when they’re very small, and we can then guide fiberoptics probes.”

Such strides will hopefully lead to faster, less-invasive treatment options for cancer patients.

—Ann H. Carlson