Wednesday, October 05, 2005

Garbage In, Garbage Out

(Image by Tim Jensen as seen on

The "C" in PACS stands for "Communications", and that doesn't just mean bandying the "Pictures" in the "Archive System" back and forth. For the radiologist, the picture is worth a thousand words, and on a Medicare patient, at least ten cents.

I realize this discussion will border on RIS/PACS integration, and that is not really where I want to go with it. I'm going to concentrate on two narrow areas, getting documents into the system so I can see them associated with the images, and getting my preliminary report out to the clinician that ordered the study.

Document scanning has been around a while. I was first introduced to the concept in 1990 when I went to visit a little company in Birmingham that had the idea to use a scanner to digitize paper and store the images. I don't know what became of that particular company, but the concept sure caught on nicely. Today, in the PACS world, a company called PacsGear sells PacsSCAN software that lets you scan in a document and transfer it to the patient's study as an additional sequence of the exam. This seems to be the most popular method of accomplishing this task. There are some other software packages, and even Merge has a module to do this, eFilm Scan, which does about the same thing. It would be nice to have this functionality built in to a reading station, or at least a QA station, but the only system I know of that does this is the MedView client from StorComm, and I think I've made my feelings about that thing pretty clear elsewhere. PacsGear also has a similar program to "print" into a DICOM study, which might allow placement of a graph or a JPEG image of some sort. Until we reach the Nirvana of a completely paperless hospital (excluding the bathrooms, I would think), paper history sheets and the like will still be around, and we need this sort of solution to at the very least stem the flow of paper to my desk. Hey, it's a start!

The most brilliant radiologist in the world (obviously not me) is worthless if his or her interpretations don't get where they are needed in a timely manner. There are many solutions to this little problem, some of which are actually practical:
  1. Call the result to the ordering clinician. They love it when I do this, but you just can't call each and every case and still have time to read the day's stack/pile/worklist.
  2. Yell it out to your secretary/aide/resource person so they can call it in for you.
  3. Dictate it and press some sort of priority key which, in theory, is connected to a buzzer or electroshock equipment somewhere in the vicinity of your transcriptionists to alert them to drop everything and transcribe your study first. They are then to fax it or read it over to the phone to the illustrious ordering physician, or at least to one of his/her minions.
  4. Dictate into a voice-recognition system, edit the report, autofax it to said illustrious clinician.
  5. Type a brief preliminary report into the appropriate field in the PACS system; the clinician knows to look here as soon as the exam is toggled as "read".

Of all these wonderful options, I like the one where I yell at my helper, but good helpers are hard to find these days, especially if you yell at them constantly. From various threads on the VR topic, I am firmly convinced that it is not ready for prime time, and has the potential for administrative abuse in replacing transcriptionists with radiologists who are forced to do all the editing themselves. Sorry, I have enough going on during the day that I don't need yet another job-title. I suppose the absolute ideal would be a transcription pool so vast, fast, and accurate that the minute I press "end", the report is en route to its destination. All that takes is a tremendous amount of money, right? No problem. Oh well, it looks like Option 5 seems to be the best compromise, at least for stat call reports to the ER and to others similarly equipped with PACS viewers.

This should be a simple task, but alas, it isn't as easy as it looks. The big question is where do you put this "comment window", and how do you signal the docs that there is something to be read? Rather than give you the blow-by-blow (or the yawn-by-yawn) of which company does what, let me create the image in your mind of the perfect woman, oops, I mean perfect comment system...had you going there, yes? Personally, I'm a one-stop shopper. Give me the Mall of America with a zillion stores under one roof rather than Michigan Avenue where I have to walk outside in Chicago weather, which ain't pretty around RSNA time. I want a complete, combined demographic and comment window, with a field for me to type in my own, well, comments. There should be a flag on the worklist to show if there are comments from the technologists and/or the radiologist. If your worklist doesn't take up the entire screen, it would be nice for this window to live below the worklist, and be populated with the proper information for the active study. Otherwise, it could be a floating window that appears when you click the study for display. Simple enough, yes? OK, someone go program this and let me know when its done. I'm going to go yell at my helpers.


I think I need to flesh this out just a little more. We are having a bit of a discussion with Amicas about whether or not this Super Duper Whiz Bang Master Comment, Demographic, and Preliminary Report window should pop up all by itself or not. My PACS admin thinks it should, but frankly, I really am not all that concerned. I like to have the option to do it myself. The auto-pop-up thing acts too much like a pop-up ad for my taste, plus it usually ends up covering something I want to see anyway. I would just as soon click a button to get it. BUT, I would like to see a flag on the worklist to show if there is a technologist or a radiologist comment to be viewed.

Agfa has a potentially useful addition to its comment field: precanned preliminaries. This saves you from typing the same thing 5,000 times a day. It's a good idea, but their implementation is typically harder to use than it has to be. (Are you listening, Waterloo?) You click in the comment window which spawns a second comment window which in turn has three panes (as in window panes). The top pane has the precanned report selection, the middle is a free-form area to write your own, and the bottom shows the conglomerate of your selections. The odd thing is, you can type directly into the bottom, final pane, so why the middle one? I must be missing something. When finished, you must click Save, which places your beautiful prose back into its proper field in the information window. Ducky. Why can't we just type straight into that area, huh? Doesn't allow for precans you say? Well, how about making the precans available by via right-clicking in the field? I like it, although if you have too many precans you might end up with a famous case of Dalai's Right-Click-O-Rrhea. It's worth the risk in my opinion. All systems need to autostamp with ID, time, and date, and that has to be permanent. No fair going back and changing all of your partner's preliminaries to "normal" or "31 week gestation". OK, guys and gals...get programming!


Anonymous said...

Please provide comments on AGFA vvs Amicas PACS workstations from a Radiologists perspective...
Regards, Jay

Anonymous said...

Dr Dalai,

If you don't mind, I'd also like to hear your comments on Amicas. My group is looking into it and I want to be sure we're going down the right path. Out radiologists are... impatient and I'm more concerned about speed over anything else.

I can be reached at:

Thanks in advance.

Anonymous said...

Regarding document scanning:

Sectra offers just what you ask for - since years:

Keep blogging!

DHS said...

I don't know if your dictation / transcription is integrated into your phone or web system (I've worked at places with each), but being able to be text paged when the report is dictated (not transcribed!) for an urgent scan so that you can go check on the recorded verbal report would be valuable.

"CT REPORT ON MRN 123-45-67 IS NOW RECORDED" --> go jump on a workstation and listen to the radiologist's soothing voice.