Technology is usually the first thing that people think will ease their workflow challenges. Throw money at a problem, and it should go away. But technology is not a Band-Aid, a fact sometimes discovered after having already spent the money. Human factors, including behavior, can have a greater impact. Sometimes, just getting people to accept technology can create challenges by itself.

Of course, it doesn’t mean that technology cannot help. Even in challenged work environments, installations of RIS, PACS, and EMRs have resulted in improved turnarounds, reductions in error rates, and greater satisfaction?by both patients and physicians. In these departments, if technology is implemented alongside positive human factors, even greater improvements can be seen.

Five Factors

Workflow challenges have four dimensions, according to Mark Profio, advanced applications lead system designer for workflow at GE Healthcare (Waukesha, Wis). He lists:

  1. The increased use of medical imaging that is driving growth: “This is not related as much to demographics as to growth in core imaging and other applications, such as cardiac and stroke workups in the emergency room. There’s been about a 20-percent increase in demand”;
  2. The shortage of radiologists and technologists, a situation not expected to improve soon;
  3. Lagging training for new neuroimaging techniques, which is related to the staff shortage; and
  4. A data explosion resulting from the more advanced technologies, such as 64-slice CT: “Radiologists can get an unprecedented amount of information for postprocessing.”

Mark J. Halsted, MD, chief of the Informatics Research Core for the Imaging Research Center at Cincinnati Children’s Hospital Medical Center, suggests there is one more dimension, related rather ironically to technological advances. “Systems, such as RIS, PACS, and voice recognition, allow radiologists to improve productivity and service,” Halsted says, “but they also increase the expectations of others so that the demands placed on radiologists, such as 24/7 access, often increase.”

Swimming Upstream

Many practices already have installed much of this current technology, including RIS and PACS. And those that haven’t are working on it, according to Halsted. Assuming this is the case, many radiologists find that one of their biggest challenges becomes interruptions, he says.

“There are constant calls for results and interruptions for new requisitions,” Halsted says. “More medical decisions rely on radiology results, and we’ll get calls for reports before the patient has even made it back to the ER.”

Interruptions also come in the form of communicating and documenting critical results. “Not only is calling [on the telephone for clarification or to deliver results] the right thing to do, but the radiologist can be held liable for an unexpected tumor unnoticed by the primary care physician, if the radiologist fails to close that communication loop,” says Halsted, who explains how radiologists can deliver that information without breaking workflow.

Small interruptions throughout the day can amplify into larger workflow problems. “When things don’t go as expected, it has a cascading effect. The technologist is busier, the room is busier, the patient gets held up,” says Todd Minnigh, global director of marketing for Eastman Kodak Co (Rochester, NY). “Whether it’s an incorrect requisition or the wrong patient name on the image, the department needs the ability to correct mistakes or manage exceptions.”

According to Jacob Philip of IMPAC Medical Systems, the company's solutions?which focus on oncology?help to plan and deliver treatment in more efficient ways.
According to Jacob Philip of IMPAC Medical Systems, the company’s solutions?which focus on oncology?help to plan and deliver treatment in more efficient ways.

Inflexibility can be an efficient workflow’s greatest challenge, according to Scott Simpson, RT(R), clinical analyst for MD Buyline (Dallas). That rigidity can come from within. “Oftentimes, workflow can be negatively impacted by behavior,” Simpson says. “Some people will work against new technology.”

Workflow Mapping

There’s no one way to solve behavioral problems. “Individuals have their own reasons for their behavior, but open communication about the goals of the project and the desired workflow can help them see how they’re negatively impacting those goals and the workflow,” Simpson says.

By documenting current workflow and comparing it to the future, desired workflow, you can determine what needs to be different and how behavioral changes impact the process. Workflow mapping also will help to identify ways to streamline. For example, what, if any, are the unnecessary steps in the imaging process?

“Procedures often are unique to each institution. As staff, processes, and equipment change, legacy workflows continue,” Kodak’s Minnigh says. For instance, one medical-imaging department still might keep a local record of every study even though they are backed up on PACS and in an off-site location. This extra backup step can, and should, be eliminated. Mapping workflow can identify these legacy processes, and, at the same time, it can suggest technology that can complement workflow, Minnigh says.

But workflow mapping also might provide information on where changes in behavior or processes unrelated to technology can be helpful. “Behavioral observation, documentation, and analysis are the primary steps in the process of finding creative solutions,” Simpson says.

Low-Tech Solutions

Thinking “outside the box” can result in changes that do not cost much money or require new technology but can have a big impact.

Minnigh suggests that scheduling can benefit from a broader view. “Departments should look at when they do certain exams, why they do them, whether they are needed, and in what time frame they must be completed,” he says. “Often, times of intense pressure are put on a certain area. For instance, [let’s say] a large portion of chest X-rays can be scheduled routinely during the morning from 7 am to 10 am, while only two are requested during the hours of 2 pm and 4 pm. Why? Can this load be redistributed?”


Scheduling software boosts performance of breast clinic

The Elizabeth Wende Breast Clinic (Rochester, NY) serves more than 300 patients per day and performs 54,000 mammography screening procedures per year. Seeking a more efficient scheduling process, the clinic worked with Eastman Kodak Co (Rochester, NY) to create a new daily scheduling system.

Kodak’s Workflow Optimization Service first conducted a workflow study using a list of screening questions to help staff determine which patients needed to be seen the same day and which could wait. A certain number of emergency exams were expected every day.

The resulting process was so efficient that the clinic found it was able to handle an additional 500 to 750 patients per month. At the same time, the number of patient reschedules reduced by 80%, patient satisfaction rose to 90% (a 10% improvement), staff satisfaction improved by 64%, and overtime decreased.


Another area where improvements often can be made is staffing, according to Halsted. “It’s obvious that as studies, slices, and images increase, we need to deal with the staffing shortage. We don’t expect a reversal, yet there often still is resistance to hiring additional help,” he says.

That help need not necessarily be a radiologist; in fact, it often should not be. “Ancillary staff can help to make the work run more smoothly,” Halsted says, noting that these persons?located near radiologists for easy access?can answer phone calls, look up information on the RIS, coordinate exams, and prep patients. “They don’t necessarily replace traditional radiology tasks, but they allow the radiologist to focus.”

Even though this idea might be met with resistance from administration, it can help to save money. Extenders answering the phones will cost less money than radiologists, who will be happier. “It is far cheaper in the long run to provide adequate support than it is to support a cycle of recruiting and losing radiologists because of an inefficient, frustrating workplace,” Halsted says.

However, extenders cannot handle all tasks?certain issues will require a radiologist. So Halsted’s team set up the affectionately called “hit me box.” Radiologists rotate through this position, which is known as the spot where people go with questions, such as prioritizing add-ons or protocols.

Additional help also can come in the form of other physicians. “We hired a full-time pediatrician to handle the sedation of children for CR and MRI,” Halsted notes. She freed the radiologists from dealing with this task while also improving care. Not only did she have more related clinical experience, but she also provided a consistent face for returning patients. “It’s a more efficient use of money,” he says.

High-Tech Solution

Once the team has become a well-oiled machine, real machines can then help improve performance even more. Halsted’s team devised a software solution to their biggest challenge: interruptions and results communications. The RadStream system fills in gaps in the workflow that normally would have taken radiologists’ time or impacted patient care.

The solution is entirely paperless and supports decentralized dynamic workload balancing, fosters automatic communication and documentation, and decreases interruptions. Cases are entered into the system; then, they are sorted by priority using a computerized triage algorithm that, when tested, was found to have a high correlation with human decision-making. Radiologists can access each other’s lists, allowing someone with a low workload to help another who is overwhelmed. “The overall group works as a unit,” Halsted says.

Results are automatically sent to operators, who can deliver them or get physicians on the line for consults. The radiologist does not need to look up numbers or waste time waiting for callbacks.

The system, which took Cincinnati Children’s staff about 3 years to design, has produced amazing results. Turnaround has improved by 40%, with the department’s average for outpatient results down to 36 minutes. Satellites also are benefiting; according to Halsted, radiologists staffing these departments save a couple of hours per day, per radiologist.

He points out that their success was based on a solution implemented in a healthy work environment: “We have a strong support team, excellent relationships, high morale, and a single-vendor RIS/PACS with 100% use of voice recognition. Other departments will need to boost their environments to maximize the use of new informatics tools, but in doing so, they probably will see even greater improvements than we did and find it easier to recruit and retain staff.”

Hand in Hand

Conversely, those without a cooperative team might not see any improvement. “The combination of human and technology factors is key. It doesn’t matter how many electronic bells and whistles you have if the team won’t help each other,” Halsted says.

Minnigh agrees, adding, “People need to look at workflow first and make sure they understand not just what the issues are, but why they do what they do. It’s important to know what is really needed. Sometimes, folks just want to throw technology at a problem. Technology can help, but it must be done smartly.”

Standards of the 21st Century

Certain technologies have become ubiquitous in medical-imaging departments across the country. What are these new standards of the 21st century?

Traditional X-rays have made way for CR, which has made way for DR. CT and MRI have penetrated all markets, with multi-slice CT now found even in smaller facilities. Transcription is being replaced with efficient and effective voice-recognition systems. (For more details on this process, see “Can You Hear Me Now?“.)

Only a small portion of medical institutions is managing the many images and data produced by these technologies without a PACS, and most radiology departments without a RIS have one somewhere on their wish list.

Even EMRs are showing greater adoption and can expect to be standard long before this century is over. “In many cases, the EMR has become standard already,” says Scott Simpson of MD Buyline (Dallas). “EMRs will blur the line between departments, and it will become more difficult to tell where one department begins and another ends.” Sharing information through an EMR allows an institution to leverage its resources. To support an EMR plan, departments that can back up to one central archive will share data more easily.

Says Eastman Kodak Co’s Todd Minnigh, “It makes good financial sense. Otherwise, you end up with individual silos of data that require separate backup procedures and interfaces.”

EMRs have been found to increase productivity and improve care. “As information becomes available across the enterprise, providers can better produce proper decisions. Medical errors are decreased,” Minnigh says.

So paperless systems not only save trees, but also time, money, and frustration. Turnaround goes up, errors decrease, consistency increases, and everyone expresses greater satisfaction. Often, the bottom line also shows improvement.

“A key benefit of the electronic environment is that you can better manage charging, with the elimination of missed services. Customers typically improve their billing by five percent when they go paperless,” says Jacob Philip, director of radiation oncology for IMPAC Medical Systems Inc (Mountain View, Calif). That should be enough to lure laggers into the 21st century.


Renee DiIulio is a contributing writer for Medical Imaging.