Transcript Radiology Order Comms at the Homerton University Hospital

Radiology and EPR
at the Brighton Radiology Visit
• Anant Patel
• Lead Radiographer
(CG/RPS/IT/Redesign)
• Mohmed Patel
• PACS Manager
Homerton University Hospital NHS
Foundation Trust
Brighton Objectives
• Visit EPR site with radiology integration (Anant)
• Radiology Information System (RIS)/PACS &
Desk Top Integration (Mohmed)
• Applications integrated to RIS
(Mohmed/Anant)
• Q & As (Anant/Mohmed)
• ? Anything else (Brighton contingent)
Homerton University Hospital NHS
Foundation Trust
EPR at HUH
• Radiology paperless (Sept 2004) with 2
exceptions
1. Labels (contents)- act as request form
2. External referrals' (GPs/Mental Health) paper
requests
• Radiology film-less (PACS April 2007)
• Desk Top Integration (2010)
Homerton University Hospital NHS
Foundation Trust
Contents
• Radiology involvement with
Homerton/Newham Programme
• Future Flows
• Issues
• Other applications it’s integrated/interfaced
with
• The Good
Homerton University Hospital NHS
Foundation Trust
My Involvement with HUH EPR
• Involved with procurement (1999-2003)
• Radiology System Designer for Homerton and
Newham (2003-2004)
– Redesign
– Design decisions
– Additional hardware and software requirements
• Training (2004)
• Go Live then troubleshooting (2004-2005)
• Radiology EPR (2008-)
Homerton University Hospital NHS
Foundation Trust
Why Cerner?
• Cerner only one with a high level of integration (no maternity
though)
• McKesson (Bangkok) only had a few modules that were
integrated (Pharmacy/Radiology) with RIS/PACS (Toulouse)
• Siemens no real live system (Sweden), though RIS/PACS at
Worcester
• System C (Liverpool) too many interfaces and little confidence
after demos
• Cerner very good at selling from demos, to site visits (Detroit)
to HQ environment (Kansas)
• Cerner also able to demo majority of requirements on a live
system even if we didn’t understand them fully
Homerton University Hospital NHS
Foundation Trust
Once Contract Signed..
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Current flows
Design Consultancy Sessions
Questionnaire
Future Flows
Making the design decisions
Homerton University Hospital NHS
Foundation Trust
Current Flows
• Mapped paper flows
– From requesting to results going to consultant in
boxes
• Needed stronger radiology voice regarding
IRMER
– Open requesting policy
Homerton University Hospital NHS
Foundation Trust
Design Consultancy Sessions
• Sessions organised by Cerner to demo the
solution to the system designers
• Questionnaire provided to draw up future flows
• This is your clinical contract with supplier!
Homerton University Hospital NHS
Foundation Trust
Questionnaire Contents
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Order processing (Powerchart etc)
Order Entry Formats
Patient Labels
Cancel exams
Radiographer info
Radiology Report
Additional Information
Homerton University Hospital NHS
Foundation Trust
Future Radiology Patient Flows
– Four flows
• Paper GP requests direct access (XR)- Department Order
Entry
• Paper GP requests schedulable (US)- PM Office
• Direct EPR Referrals (XR, emergency CT, Mobiles etc)Powerchart/Firstnet
• Schedulable requests (CT, MR, US etc)- Scheduling
Homerton University Hospital NHS
Foundation Trust
PAPER REQUEST
FROM GP OR
OTHER
EXTERNAL
REFERRERSCHEDULED
PAPER REFERRAL
FROM GP OR OTHER
EXTERNAL REFERRERDIRECT ACCESS
ELECTRONIC
REFERRAL –
DIRECT ACCESS
ELECTRONIC
REFERRAL –
SCHEDULED
GP/MH Paper
Referral
(e.g. US)- PM
Office
GP/MH Paper
Referral
(X-Ray)- Dept
Order Entry
Internal Electronic
Referral
(X-Ray)Powerchart/
Firstnet
Internal Referral
(US, CT, MRI)Powerchart/
Firstnet
Add patient to
Radiology Wait
List- PM Office
Paper form is
brought to desk
and entered onto
Dept Order
Order is made via
PowerChart in O/P
Clinic
Request list is pulled
from Scheduling
enquiry by reception
staff
Radiologist vets
referral form and
assigns priorityPaper Request
Schedule patients
as Routine
booking in
Appointment Book
Reception staff
prioritise the
referral on wait
list- PM Office
Schedule Patient from
Wait list (Person who
vetted is entered as
Ordering Physician)Scheduling
Vetting done via
Rad online worklist
(EPR)
Requests the exam as
part of Scheduling,
changes Rad Request
to the priority assigned
Urgent/Routine
Letter
sent to Patient
Confirm
appointment and
give appt. letter to
Radiologist to vet.
Vetting done via RDT
Vetted by is ticked and
Priority is changed
from Rad request
Check in Patient
and Modify
Encounter at
ReceptionScheduling
Contents Label Printed at nearest label printer
Letter
sent to Patient
Clinical details checked/previous reports and exam
started by Radiographer- Rad On Line Wklist (EPR)
Rad completes exam from Modality
Worklist (DMWL)
Radiographer
Checks out Patient if
scheduledScheduling
Rad completes exam from Rad On
Line Wklist (EPR)
Reading Radiologist set on
PACS
Radiologist/Rep Radiographer uses PACS Reporting Wklist
which is bridged with EPR
Report is dictated by Radiologist with
Voice Recognition RDT
Report is signed out by Reporting Radiologist/Radiographer/Sonographer via RDT
Homerton University Hospital NHS
Internal report goes into
Foundation Trust
PowerChart/Firstnet/PACS
GP/MH Report printed
and sent electronically
GP (Paper) Flow- A&C
• Paper details copied to EPR Ordercomms
– Not scanned, as could be easier for coding
• Appointments added to electronic wait list
– A&C initially schedule
– Vetted/justified and rescheduled/cancelled/changed
if necessary
– Letter to patient
• Direct Access entered onto Ordercomms
• Exam to RIS worklist for that day
Homerton University Hospital NHS
Foundation Trust
OP/IP/A&E (Electronic) Flow
• Requested electronically (referrers)
• Appointments (A&C staff)
– Queued then scheduled by A&C staff
– Vetted/justified by IRMER pracitioners
– OP Letter sent, otherwise IP/A&E verbally notified
• Direct Access (non-schedulable) straight to RIS
Worklist for the day
Homerton University Hospital NHS
Foundation Trust
Scheduling (Electronic) Flow
• Check in (A&C) patient and ensure correct
encounter selected
– Notification when patients have checked in (status
changes from Red to Yellow)
• Check out (Radiographers) patients
– Notification from Yellow to Red
• Correspondence module associated to
scheduling difficult to change for specific
exams/modalities
Homerton University Hospital NHS
Foundation Trust
Radiographer Flows
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Check previous exams
Start/complete/vet exam
Add image usage/contrast/dose information etc
Ensure data transferred to PACS
Homerton University Hospital NHS
Foundation Trust
Radiologist Flows
• PACS centric flow
• Use templates or VR to dictate
• Sign immediately
Homerton University Hospital NHS
Foundation Trust
Future Hardware Flows
• PCs at all areas where paper was used (viewing
areas
• Label printers for radiology and pathology
(biopsy/drainage procedures)
• Voice recognition/digital dictation hardware
Homerton University Hospital NHS
Foundation Trust
Other Applications linked with
Radiology (RIS/PACS)
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Powerchart (Nurse/Dr Application)
Firstnet (A&E dept)
Scheduling (OPD, Radiology, Theatres)
PMOffice (PAS)
Surginet (Theatres- not required)
Casenote and Film Tracking (?)
Winpath (not Pathnet- Pathology)
Keystone (electronic reports to GP via interface)
BT/Sectra PACS (via Insignia PACS)
Homerton University Hospital NHS
Foundation Trust
PACS-EPR
Homerton University Hospital NHS
Foundation Trust
Order Entry Format Design I
• Which fields needed?
• Which fields are mandatory?
• Which fields are mandatory in Powerchart (electronic
requests)?
• Which fields are mandatory for paper requests
Department Order Entry (DOE) ?
• Which fields are mandatory in PM Office (paper) and
Scheduling (electronic)?
• See Synergy Article (Patel and Hogg 2009)
Homerton University Hospital NHS
Foundation Trust
Issues I- Technical
• Support (in house very very limited resources)–
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Non clinical
New services – Mammos 4 years to develop
Ca wait data hard to collect from CDS
Updating slow- Mental Health/Podiatry referrers
*Recommend similar model to BT helpdesk*
• Not full integration between Radiology and Scheduling
– Fields (consultants don’t carry over)
– Cancelling scheduled appointments and then the exam
• Servers overloaded
Homerton University Hospital NHS
Foundation Trust
Issues II- Clinical
• IRMER– Workaround having schedulable to orders, i.e. vetting
– Non Medical Referrers, Open Requesting Policy
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Delays in lack of desk top integration (clinical risks)
Encounters (patient episodes)- ZZ Section
Clinical details (wrap around text)
Obstetric US not integrated (separate system)
More Radiology specific code sets (cancel reasons)
Homerton University Hospital NHS
Foundation Trust
Issues III- Multiple Sites
• Standardisation of flows
– Mostly the same
– Workarounds when there are not
• Newham patients coming across to Homerton
– Requires IT admin communication between sites
Homerton University Hospital NHS
Foundation Trust
Issues IV- Targets
• Ca not identified- still manual
• Difficult to quickly look at waiting times, need
an Information report
• Information reports needed to be created by IT
not RIS manager and dependent on a particular
download
• Current lack of awareness of DSCN 14/2009
and DSCN 18/2009
Homerton University Hospital NHS
Foundation Trust
Issues V- PACS via Broker
• Messages not always going across
– Patient merges is intermittent
– Minimum updates go across
– Messages from DMWL do go across
• Accession Linking reports not automatic
• Clinical risks due to lack of DTI
Homerton University Hospital NHS
Foundation Trust
Issues VI- Misc
• Communication
– Need to test every change to the system even if not
directly connected with radiology e.g. new isolation
field code set
– Paper work immense to get a change, more than BT
PACS
• Downtime/Contingencies
– Full
– Partial
Homerton University Hospital NHS
Foundation Trust
Additional Benefits
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Incidents- were auditable via Powerchart
Incidents- picked up via PACS
Privileges for referrers (non medical)
Monitor work from any PC
Homerton University Hospital NHS
Foundation Trust
Good
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Couldn’t go back to old system
Couldn’t go back to paper system
Paperless except labels/consent forms
Messaging goes across to PACS most of the time
BT managing PACS, unfortunately not HUH EPR
Request ‘forms’ can be vetted from anywhere
Most actions auditable via information dept (from
requesting, to rebooking)
Homerton University Hospital NHS
Foundation Trust
References
• Patel, A., and P. Hogg. 2009. Cutting the
Paper Chain. Synergy, September 1, 2630. http://www.proquest.com/ (accessed
November 16, 2010)
Homerton University Hospital NHS
Foundation Trust