integration technology for efficient radiology T. Wendler 1 and C. Loef 2 Radiology is changing rapidly. In the healthcare system and in radiology as an integral part of it we are facing a challenging situation of shrinking budgets, increasing cost pressure, and growing demands to increase both the efficiency and the quality of services. Reacting to these challenges, healthcare enterprises increasingly rely on Information Technology (IT) solutions. In digital imaging departments, typical IT environments consist of various application systems: hospital information systems (HIS), radiology information systems (), picture archiving and communication systems () and imaging modalities. Historically, these systems have been designed and developed by different communities, and are typically implemented and installed by different vendors. End users of systems are not generally interested in the technology-induced fragmentation of their IT infrastructure: it is simply a hindrance to providing an efficient service. Integration of application systems is therefore an urgent requirement, and the object of increasing attention. In the past, most of the efforts to make multi-vendor systems work together have focused on the integration of information. We now have working standards that support data exchange: DICOM (Digital Imaging and Communication in Medicine) and HL-7 (Health Level 7). In 1998, the IHE (Integrating the Healthcare Enterprise) initiative was started as a five-year effort with the goal of achieving seamless integration of information, and to support the clinical workflow by specifiying a technical framework showing how vendors should use standards such as DICOM and HL-7 in multi-vendor installations [5, 6]. With respect to radiology, access to information is an important aspect, but not the only one. We are beginning to understand that the transition from film-based to digital systems is much more than a change in the technology for storage, distribution or display of data. We now see that these changes are accompanied by simultaneous changes in the processes of radiology and the organization of work. Furthermore, new socioeconomic boundary conditions are forcing healthcare institutions to optimize or completely redesign departmental processes to meet their essential medical and commercial targets. Business process re-engineering (BPR) and process automation ( Management) are increasingly seen as key factors for the successful operation of digital imaging departments and hospitals. This is in line with observations from other business sectors (e.g. banking and insurance) which are similar to healthcare in the sense that professionalism and success are based on a strict approach to customer orientation and cost effectiveness. In these sectors, process awareness and the use of tools to manage processes and organizations are much more common than in healthcare. This article addresses the workflow aspects of radiology, and the perspectives for using workflow technology for more efficient radiological services. Process integration and workflow : the present situation The application systems currently in use in radiology are rarely designed to explicitly and dynamically support changing processes and flexible organizations [1, 3]. Many of the reports on the improvements in efficiency and reduction in costs after installation of IT claim moderate success, but do not sound overenthusiastic. Usually, the workflow aspects of installed systems are dealt with in timeconsuming and expensive projects, rather than in product features that would support this important aspect of system integration. We lack effective concepts to deal with business processes on the departmental level as well as on the hospital or healthcare system level. Due to the separation into isolated application systems, it is common for workflow aspects in radiology Integration of application systems is an urgent requirement. technology can increase efficiency. 1 Philips Research Laboratories, Hamburg, Germany. 2 Philips Medical Systems, Best, the Netherlands. MEDICAMUNDI 45/4 November 2001 41
Some degree of integration has been achieved in the multi-vendor environment. DICOM is the essential image-driven standard for radiology. Figure 1. aspects. Business rules, medical, political, economic, legal, time constraints Rooms, work places Consumables, resource Control Location Material to be spread over the entire information system environment (i.e., functionally distributed over HIS,, and modalities). This has a number of clear drawbacks, such as: preventing an integrated overall view of processes and organizations creating overlaps of the existing workflow functionality implemented in the various subsystems, especially in multi-vendor environments preventing adaptation to the specific and changing needs of institutions (process reengineering and optimization), making changes expensive and often impossible. What we have achieved so far in the multi-vendor environment, based on the DICOM and HL7 standard, is the integration on the data level and the of the workflow for the image acquisition process at the modality. For example, the DICOM Modality Worklist standard is supported in all Philips modalities, and support for the Modality Performed Procedure Step standard, which enables the tracking of the image acquisition work, is growing. In practice DICOM is the essential image datadriven standard for radiology, and provides support for workflow at the individual process step level. Recently the DICOM standard has been extended in the workflow direction with the specification of the General Purpose Worklist, which may be used to schedule and monitor the execution status of all sorts of tasks in the radiology department. However, the scope of these extensions is restricted to isolated activities within the radiological process, and they do not specify the collaboration between Patient flow, scheduling, tracking Patient Activities, sub-processes Function Information Organization Flow Operation Human resources, staff, roles, organizational Sequences of activities, process Equipment application systems, devices, tools data, documents, data workflow managers that is needed for department or hospital-wide workflow-driven solutions. Integral views on the overall workflow in a department or hospital are not provided yet. What we envision for the future are systems that would conceptually support workflow. There are demands to move forward and take the next logical step from pure data to an environment with integrated data and workflow services. It would be beneficial to proceed to radiological information systems (RIMS) that are explicitly designed to contribute to efficiency, costeffectiveness and a high standard of medical services. In addition to the usual data services, they would provide flexible support for the key processes and organization in changing medical institutions. This would assist the radical process re-engineering in departments, as well as the permanent optimization and automation of processes to meet economic and medical needs. Management Services with modelbased enactment of workflow should be integral parts of medical IT solutions. The Management concept and its application in radiology are dealt with in greater detail below. In the context of automation, workflow is a frequently used keyword with a specific meaning. Unfortunately, the term is often restricted to describe certain aspects of data flow, instead of focusing on processes. For clarity, we recommend the standard definition of workflow in automation as proposed by the Management Coalition (WfMC) [2, 4], which is the most important standardization body in this area: is the automation of a business process, in whole or part, during which documents, information or work items are passed from one participant to another for action, according to a set of procedural rules. deals with processes. The flow of data is just one important part of it. Other aspects (see Figure 1) include: process (modeling the sequence of activities), organizational (modeling all aspects of human resources), 42 MEDICAMUNDI 45/4 November 2001
of operational units (equipment, devices, tools), managing locations (rooms, workplaces) and material (e.g. consumables), modeling and tracking of patient flow, and the adherence to all kind of business rules that define medical, political, economic, legal or time constraints. aspects of radiology Radiological processes consist of numerous welldefined activities which are performed by different people or systems, in different locations and at different points in time. In a digital department, most of these activities are supported by computerized application systems and appropriate software components within these systems. Figure 2 shows a simplified but typical view of radiology from the workflow standpoint, emphasizing the global process aspects. The left- and right-hand sides of the diagram show application system components which are implemented as functional modules of HIS,, or modalities. These components support the well-known radiological activities. The center of the diagram shows an explicit notation of the process itself, describing the sequence of activities for this simple workflow example. The drawing illustrates the meaning of workflow integration: all of the application system components shown will be invoked in the various stages of the process. No single application system has an integral view of the entire process, so that the conceptual independence of workflow and application systems becomes obvious. -driven solutions will have explicit of processes. To achieve this, we have to add another system to the radiology IT environment as visualized in Figure 3. Data bases and application functions of HIS/, and modalities are complemented by a workflow service with data bases for processes and organizations, and workflow functions to enact processes. In current IT environments, there are no explicit definitions or implementation of processes, preventing us from designing, optimizing and implementing processes. In well-designed processes, many activities can be automated, for example pre-fetch images or functions Process functions Image pre-fetching Image archiving Image viewing Activity function function Modality function Application invocation Sequence of activities Start process Schedule examination Prefetch images Perform examination File image Read image Transcribe report Authorize report Submit results Register patient arrival submit results as shown in Figure 2. Process automation can significantly contribute to high throughput and fast response times. This can be expected to result in improved efficiency and satisfied customers (e.g. through minimized waiting times for patients and fast delivery of results to referring physicians). Supporting processes means that all activities in an institution have to be considered, and all of the function o Process & rganizational information End process Management System (MfMS) Application System Image information functions Register billing date functions Medical & administrative information Modality functions Request registration Examination scheduling Patient arrival registration Modality functions Examination Billing Report transcription Report authorization Result delivery Figure 2. aspects of radiology. Figure 3. Components of Radiology Information Management Systems (RIMS). Application System Application System Modalities MEDICAMUNDI 45/4 November 2001 43
Generic activity Typical workflow participants Typical locations Typical application system Pre-visit administration Register request Schedule examination Pre-fetch information Register patient arrival Secretary Secretary Receptionist Office Office Reception Image generation / exam. Pre-examination viewing Generate images Post-examination quality check Register billing data, radiographer, radiographer, radiographer Radiographer Exam room, any Exam room Exam room, reading room, any Exam room, any Modality WS, SCD-WS, any WS Modality Modality WS, SCD-WS, any WS Post-exam administration Pre-load images Archive images Image reading and reporting Read images Dictate report Generate preliminary report Reading room Reading room Reading room SCD-WS / Dictation system Post-reporting administration Transcribe report Authorize report Submit results Billing Secretary Office () Office, reading room, any /Speech recognition system, SCD-WS / / HIS Post-visit image re-viewing Prepare conference Conferencing Clinical viewing Re-view images in radiology Teaching Viewing anywhere Referring clinician any physician Conference room Conference room Clinical dept. any Conference room anywhere Conference-WS, any WS Conference-WS Clinical WS SCD-WS, any WS any WS any WS (Wendler 72000) Table 1. Typical sub-processes and activities in radiology. The various processes in radiology have to be identified, modeled and automated. application systems involved must be integrated. solutions have to be autonomous, i.e. independent of,, and modalities, particularly in multi-vendor environments. Thinking even further, we should keep in mind that processes in radiology represent only one service (sub-process) in a healthcare enterprise. Technology for supporting processes has to be scalable to at least the enterprise level, if not to the level of the entire healthcare system. Processes in radiology The various kinds of processes in radiology have to be identified, and ways have to be devised for modeling and automating them. Processes consist of logical sequences of typical activities. The most frequently occurring generic activities in a typical department are listed in Table 1. These activities are generic in the sense that they are found in almost all radiology services worldwide. Dependent on local circumstances, processes in radiology exhibit a considerable amount of variation between departments, hospitals and countries. The actual sequence of activities may vary according to local preferences, legislation, the installed technical infrastructure, or other factors. For instance, different processes may be defined for given examination types, types of patient (e.g. in- or outpatients), requesting departments, current clinical problems, patients condition, weekdays (e.g. changing services on weekends), or time 44 MEDICAMUNDI 45/4 November 2001
ad hoc not automated Ad hoc case processing Cooperative group process continuum of process Embedded group process Ad hoc exception well structured highly automated Well-defined process Figure 4. The continuum of processes (from structured to ad hoc ) in radiology. Emergency case Target for groupware Complex case Study with complex, difficult examination Target for workflow Study with spontaneous, additional examination Standard study of the day (e.g. different processes for night or day). Activities may be automated, or performed manually by workflow participants. Making the radiology services more efficient makes process changes unavoidable. Moving from batch to real-time reporting, for example, will dramatically change and partly automate essential parts of the reporting sub-process. In general, processes can only be modeled and automated if they are repeatedly performed in the same way, i.e. if they have a distinct structure. Radiology comprises a whole continuum of processes ranging from extremely structured (e.g. standard studies) to completely unstructured (ad hoc) activities. Examples of this process continuum are shown in Figure 4. However, as in other service-oriented areas such as banking or insurance, most processes in radiology are highly structured. This is particularly true of frequently and routinely performed examination types with high volume production, such as chest exams. studies have shown that approximately 80 % of the examinations fall into this category, providing a good basis for the application of workflow principles. Ad hoc type processes (e.g. emergency situations) have to be supported by other groupware technologies. Management technology in radiology The automation of business processes (workflow ) is based on the explicit modeling of processes and organizations, and the enactment of instances of these in operation by workflow engines [1]. The base technology for implementing this concept is represented by Management Systems (WfMS). concepts lend themselves to the work of the Organization structure part of system participants controls assigned to use Process instances of Process instances composed of Activities invoke Application systems are Automation is based on modeling of processes and organizations. Figure 5. concepts and terminology. Application Data work on, HIS,, modalities MEDICAMUNDI 45/4 November 2001 45
Figure 6. and application system architecture. Start process Start End WfMS CT CR MR interfaces (WfMC) US X-ray Request registration Modality functions function Data interfaces (DICOM, HL-7) function Off-the-shelf systems can be used to create an autonomous workflow service. Users can define, create and manage the execution of workflow. Management Coalition (WfMC), and have been elaborated in depth elsewhere [2,4]. Part of the workflow terminology is summarized in Figure 5. A workflow system provides means to: model the processes in terms of activities and state-transitions model the organization in terms of organizational units and workflow participants match workflow participants and activities put processes into action and provide worklists for the application systems. During the operation of an IT environment, previously defined process are selected (e.g. specific for pre-defined examination types), instantiated (put into action), and enacted (executed step-by-step by interpreting process definitions). In radiology, the typical trigger event for starting a particular process is the registration of a request for a specific kind of radiological study. After the start of the process, the sequence of events takes place according to the process model. The activities that represent each step are either fully automated (e.g. pre-fetching of images, which is performed by a component) or done manually by workflow participants. In the latter case, work items are passed to workflow participants (the end users of application systems) in terms of worklists, which will be presented to these users in the appropriate form of their dedicated application system. Typical examples are worklists such as Cases to be reported for radiologists in a softcopy diagnosis workstation, or Arrival registration of scheduled patients in a component for receptionists. An autonomous workflow service can be built using workflow technology implemented in commercial off-the-shelf workflow systems (WfMS). These systems allow users (e.g. department administrators) to define, create and manage the execution of workflow through the use of software, running on one or more workflow engines. For defining, convenient graphic editors are available. Until now, workflow systems have mainly proven their usefulness outside the healthcare domain. There are more than 100 commercially available WfM-Systems on the market, with very different implementation strategies and modeling paradigms. Application-independent and process-oriented systems appear to be promising candidates for use in radiology. -enabled application systems Following the workflow approach, future application systems have to fit into workflow architectures. These workflowenabled applications need in addition to data-oriented (DICOM, HL-7) interfaces connections to the department s or the hospital s workflow enactment service. The global system architecture for application systems in radiology 46 MEDICAMUNDI 45/4 November 2001
is shown in Figure 6. Ideally, workflow services will be provided to all application systems via standardized interfaces. A set of such interfaces has been proposed by the Management Coalition [4]. These interfaces, however, are in various stages of standardization and still have to mature. For the time being, proprietary interfaces are provided by WfMS manufacturers. This indicates that the definition and consolidation of workflow architectures in a multi-vendor effort is certainly the next essential step for the introduction of workflow concepts in radiology. Figure 7 shows the basic structure of a workflowenabled application system. The worklist handler, which is a specific interface component, provides the connection to the workflow service. The user interface for the end user of the workflow-enabled information system will, in most cases, not be very different from today s systems. The main difference will be the appearance of worklists on the screen with work-to-do items that reflect the current status of the active process instances. Figure 7 also shows the user interface elements of a workplace for the department administrator. The workflow administration interface has graphic editors to define or change processes and organizations, and to monitor the status of processes during operation. Benefits and perspectives In summary, a workflow approach to radiology appears to offer a number of clear benefits: Dynamic adaptation. It becomes possible to react quickly and to adapt the organization of the department to the ever-changing needs Improved efficiency. The automation and optimization of processes will result in reduced costs and faster response times Improved effectiveness. Optimized result delivery will increase the medical quality and outcome for the patient, as radiological findings will be available in time to influence therapeutic decisions and patient (e.g. real-time radiology) Customer orientation. Unnecessary waiting times are avoided for patients and those requiring services, giving the department an advantage over competing institutions service administration GUI Organization model editor Outcomes analysis. Permanent monitoring and control of essential process parameters can give quantitative indications of the department s performance and provide the tools to improve it. Conclusion enabled application system handler Process model editor Application system component Application GUI Process monitor Current IT solutions in radiology are predominantly data-focused and do not provide sufficient support for workflow. Management is an integration technology focusing on processes. It appears attractive for the automation of the majority of structured, routine processes in radiology, and can be beneficially applied in radiology to improve efficiency, cost-effectiveness and quality of services. Commercially available Management Systems (WfMS) can improve performance in radiology, because they provide flexible and easy-to-change implementation of radiological processes and organizations, customization of workflow by a model-based approach, and a paradigm for the processoriented integration of radiological application systems (HIS/,, modalities). The introduction of generic, process-independent worklist handlers makes radiological application systems workflow-enabled. This means that all relevant workflow participants (e.g. radiologists, receptionists, secretaries, and technologists) will be supported in process-oriented working. Autonomous workflow services will facilitate the implementation of workflow in Data services Application GUI (end user) Figure 7. -enabled application systems. Current IT solutions provide insufficient support for workflow. Management Systems can improve performance. MEDICAMUNDI 45/4 November 2001 47
will require a multi-vendor effort. multi-vendor environments. This concept calls for common architectures and standardized interfaces between the WfMS and the various workflow-enabled application systems. This will require a multi-vendor effort, and is a prerequisite to make this concept work. Acknowledgement The concepts presented here were investigated in the Management in Healthcare project of Philips Research. The authors wish to acknowledge the contributions of the project team members: Rüdiger Grewer, Kirsten Meetz, Joachim Schmidt and Jens von Berg. References [1] Wendler Th, Meetz K, Schmidt J. Management Systems in Radiology. Proc. SPIE Medical Imaging 98, San Diego, SPIE 3339: 216225. [2] Lawrence P. Handbook 1997. John Wiley & Sons Ltd, ISBN 0-4719-6947-8. [3] Levine B, Wendler T. System Integration. Chapter 11 in: Yongmin Kim, Steven Horii (eds.): Handbook of Medical Imaging, Vol. 2, Progress in Medical Image Display and, SPIE Press. In Press. [4] Management Coalition. http://www.aiim.org/wfmc/ [5] Smedema K. Integrating the Healthcare Enterprise (IHE): The Radiological Perspective. Medicamundi 2000; 44,1: 3947. [6] Integrating the Healthcare Enterprise. http://www.rsna.org/ihe. 48 MEDICAMUNDI 45/4 November 2001