ORDERCOMMS Meeting the Clinical Needs Integration with PACS and RIS Author---Dr. Neelam Dugar Chairman of The UK PACS and Teleradiology Group 21/1/09

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1 ORDERCOMMS Meeting the Clinical Needs Integration with and RIS Author---Dr. Neelam Dugar Chairman of The UK and Teleradiology Group 21/1/09 The Solution will perform 2 functions within the Trust a. Electronic Requesting b. Electronic Results Acknowledgement Current workflows--- a. Paper Request Cards are used for requesting b. A pile of paper reports are signed off Measure of Success of the Project a. Move from paper cards to electronic requests (because of ease of use) b. Move to electronic sign off of reports due to ease of use. Doctors on wards/clinics will only accept a electronic systems if it actually is superior to existing paper based systems. If electronic requesting is more cumbersome than paper based systems, we will have clinical teams continuing to use paper for both functions. If Clinical teams continue to use paper, we will definitely have a failed project as a huge amount of money would have been spent but no benefits achieved. Although, Trust could tick a box to say that has been implemented, the real implementation success in the project lies in the ability to change the culture amongst the clinical teams. Unnecessary mouse clicks need to be avoided as every additional unnecessary mouse click when multiplied by every request made has a huge cost to the Organization. Suppliers and IT department MUST work towards making this project a clinical success 1. Log-in Process---Single sign-sso MUST work with the system. Additional log-in and password should NOT be required, as this will come a huge costs to the Trust in terms of wasted time and will contribute to an unsuccessful project. We have implemented smartcards and Imprivata SSO. With implemention there is a potential for users to leave themselves logged on and another person comes along and makes a request under their log-in this may happen in busy clinical areas like A&E, Wards, Mau etc. This is related to cumbersome log-in processes. This is particularly worrying in environment where this amounts to forging of signature. This issue can be tackled by improving the log-in processes in these multi-user areas. The log-in process to arrive at the requesting screen on should be less than 10 secs (Anything more than 15 secs will definitely lead to log-in sharing in multiuser environments) We do take data security very seriously and this issue needs to be tackled with this project. 2. Patient Search :---Requesting doctor must be able to search for a patient using combination of name and DOB or unique ID (local PAS no or NHS number).

2 3. Reqesting an exam and synchronizarion with : When doctor decides to request a radiology exam. Through automatic context synchronization---the exam list for that should be launched on (this is presuming that doctor is already logged onto ). This will help the requesting doctor to have full access to the patient s imaging history. This prevents unnessary repeat requests of an examination. If this is not automated, then busy doctors are less likely to review the previous imaging history due to cumbersome process of having to find the patient on to see if the patient has had this previously requested or not. Requesting Workflow Automatic Context Synchronization JOE BLOGGSDOB: 1/1/01 Request: CXRClinical HistoryShortness of Breath - Radiology Local Imaging History Chest X-Ray-1/2/01 Chest CT- 16/2/01 MRI Spine PET CT Dr Harry Potter EPR 4. It should be possible for requesting to draw diagrams on. Transmission of diagrams may not be required to RIS provided there is front end integration (Context Synchronization) between RIS and. 5. MINIMISING MOUSE CLICKS: The whole process of electronic requesting needs to be quick and slick. Unnecessary addition steps and mouse clicks MUST be avoided at all cost. Every unnecessary mouse click will contribute to a failed project. This needs to be understood by the IT community and suppliers. Data fields as far as possible should be automatically populated--- a. Details of the requester from the log-in data (name, grade and contact no.) b. Patient demographics from PAS c. Requesting location from PAS d. Requesting Responsible consultant from PAS e. Requesting Department or speciality f. Requesting Institution (DRI, Bass and Mex) from PAS

3 6. DISPLAY OF VITAL PATIENT INFORMATION on ORDERCOMMS--- During the whole process of both requesting to acknowledging reports the top bar (containing demographics) on MUST display the following (which needs real time integration with PAS) a. Current Location b. Current Responsible Consultant c. Current Department/Speciality (difference between current vs requesting location and current vs requesting responsible consultant must be understood) This information must be visible at all stages of workflow a) Requesting b) Vetting c) Exam performed d) Reporting e) Report Acknowledgement NB: This is a significant patient safety issue ---as when abnormal results are identified by radiologists or consultant team acknowledging the request, they need to communicate results with the team that is currently responsible for the patient (rather than one who may have requested this). For example an x-ray may have been requested under an A&E consultant but now may be under the care of surgeons. Hence, infoemation about current location current consultant and current department/speciality is crucial. Coomunication will occur through ICE mail. 7. ACKNOWLEDGEMENT WORKFLOW: Clinical Teams should be able to draw up a list of all patients under a a. Requesting consultant code b. Patient Location for acknowledgement of results. By automatic context synchronization between and the images for the exam should be displayed on at the time of acknowledging results.

4 Results Acknowledgement Workflow Results Acknowledgement Sy... WORKLIST FOR AB(CONSULTANT ORTHOPAEDIC SURGEON) Urgent 1. Joe Bloggs-MAU MAU-Chest X-rayX Bob Wilson-SAU SAU-Abdomen Abdomen X-rayX Sarah Smith-Ward 12- Hand X-rayX Non-Urgent Hannah Floris-GP GP- Foot X-rayX Joanne Hampson-OPD OPD- Pelvis X-rayX James Bond Gun X-rayX Results Acknowledgement S... Results Acknowledgement Workflow (Automatic context synchronization) Results Acknowledgement Sy... Joe Bloggs Chest X-rayX There are bilateral lung metastasis. I note that the patient is known to have kidney tumour. Acknowledge and File Away Results Acknowl edgement S Change and Cancel Radiology Requests: There needs to be a robust process to support change and cancellation of requests between RIS and CANCEL ORDERS: These generally happen

5 a. By the clinical Team b. By radiologists at time of vetting--as the request may not be appropriate. CHANGE ORDER: This can happen at multiple levels a. by the Clinical Team b. By radiologists at vetting stage (e.g. CT with contrast converted to CT without contrast, or CT abdo converted to CT abdo-pelvis). The change is usually the exam description/code (rather than Change of modality) c. By radiographers (e.g. Requested left hand in error, but should be right hand, wrist requested when actually it should be hand etc etc). The change is exam code rather than modality. There has been much debate whether there should be a bi-directional link between RIS and. My understanding is that some RIS and suppliers have struggled with creation of a bi-directional link. Suppliers to define how change orders are going to be dealt by the 2 systems ensuring that the there is synchronization. This context synchronised 3 system (RIS, and ) desk-top should be available throughout radiology department workflow (radiologists and radiographers): a. "Requested Status"--At vetting stage--radiologists would CANCEL/CHANGE orders on ORDERCOMMS. b. "Vetted or Scheduled/Appointment given" status: Any cancellations/changes made by clinical teams/radiologists after "scheduled status" should generate an automatic alert message to Radiology appointments clerks from the system. c. "Arrived Status"--Radiographers should make the changes--of the exam code: on the system (via context synchronization). This should produce real-time synchronization of exam code with RIS and. When a request is is changed or cancelled, a automatic message should be generated and sent to the Referring Consultant via ICE mail. 9. RIS- Interface---The following information must be automatically transferred from to RIS (Radiology Information System) a. patient demographics b. Requester ---Name, contact number c. Requesting Consultant d. Requesting Department or speciality e. date of request f. exam description When the receptionist opens up the summary screen RIS order should appear as requested status. Receptionist should be able to define the room for exam and change status to arrived. There should be context synchronization between RIS and showing the clinical details at reception and all stages of radiology

6 exams (at reception, appointments, radiographer details, reporting, typing and authorising. 10. Vetting Requests on RIS: The radiologist will draw up a worklist of all exams that need vetting. At the point of vetting of radiology exams there should be automatic context synchronization between RIS and. should display a list of all radiology exams for the patient. will display the clinical details similar to request card. The radiologist may accept the request or may choose to cancel ot change the request. This workflow needs to be robust. Please see the point on change and cancel request. Vetting Workflow: Automatic Context Synchronization JOE BLOGGS NHS No Request: CT Chest History: SOB, Weight loss ORDERCOMMS Dr Harry Potter RIS Joe Bloggs NHS no Joe Bloggs NHS no Imaging History Chest X-Ray2/11/08 Chest CT 1/1/07 MRI brain 4/7/06 RADIOLOGY Accept RIS Current TITLE OF Chest SUBJECT X-ray Previous Chest X-ray

7 11. Reporting of radiology exams: There must be automatic context synchronization between, RIS and. Reporting Workflow: Automatic Context Synchronization Automatic display of Relevant Prior - Current Chest X-RayX - Previous Chest X-RayX Reporting Workflow Joe Bloggs Chest X-rayX Clinical History: Shortness of breath RIS ImaIging History Chest X-Ray X Chest CT MRI DD/VR Reporting Workflow Show EPR Current TITLE OF Chest SUBJECT X-ray Report: Bilateral chronic shadowing suggestive of PMF Previous Chest X-ray 12. STATUS SYNCHRONIZATION: There also MUST be REAL-TIME synchronization between all the 3 systems : RIS and a)requested (ORDERCOMMS) b)request Vetted (RIS) c)request held/deferred--with reason (RIS) d)scheduled or appointment given (RIS) e)cancelled (RIS/ORDERCOMMS) with reason f)arrived/attended (RIS) g)did Not Attend (RIS) h)exam performed (RIS) i)exam not performed --with reason (RIS) j)report Dictated (RIS) k)unauthorised report (RIS) l)authorised/verified Report(RIS) m)ammended Report (RIS) n)authorised/verified Report (RIS) o)report acknowledged (ORDERCOMMS/RAS) p)review requested ()

8 13. WORKFLOW TO SUPPORT RECORDING OF LOCAL SECOND OPINIONS (RIS and ): a. On the system the clinical user should be able to: a. request a review after providing more clinical information b. define the intended radiologist from whom the review is being requested b. This would need an additional status. The status would be review requested c. This should appear in the radiologists RIS reporting worklist as review requested d. Once a second opinion has been provided on RIS, the status should be report addendum, which would need to be acknowledged. d. On RIS, the workflow should allow also radiologists easily to record a review or 2nd opinion. This is particularly important for recording of 2 nd opinions provided at MDT meeting and other clinico-radiological meetings. 14.CLINICAL HISTORY: the clinical history which is entered in the should synchronize with the clinical history HL7 message field within and RIS. 15. ICE Mail and Failsafe Reports---Currently a large volume of copy reports printed to send out fail-safe reports to Cancer MDT Co-ordinators. Use of ICE mail will replace this paper based process with a robust electronic process. The secretaries in radiology will type a report on RIS. If they have a report that needs a fail-safe copy to be sent to an MDTM they will simply access and will send an ICE mail to the relevant MDT co-ordinator. There needs to be automatic context synchronization between RIS and. CONTEXT SYNCHRONIZATION or CONTEXT MANAGEMENT---this is a well recognized IT integration. It is currently used by us in radiology between RIS and. It is vital for ensuring patient safety as it prevents mix up of patients between 2 IT systems. Going back to the old pre- days where we had film packets. The request card, film and radiologist report all were found together in the film packet This is the gold standard. implementation has had a retrograde step in this regard. Request card is no longer visible to doctors who review images on. Context Synchronization between, and RIS is key to improving patient safety.