PACS/RIS/HIS integration drives workflow changes

Multisite PACS/RIS/HIS linkage among a group of London hospitals has increased radiological reporting efficiency considerably. But realizing these gains has required much more than simply integrating the software.

London's Hammersmith Hospital is well known as a pioneer of PACS, having become an early adopter of filmless radiology in March 1996. In November 2003, Hammersmith's PACS was extended to its two sister institutions, which already shared a common radiology information system and hospital information system with Hammersmith. Film was withdrawn, and Hammersmith, Charing Cross, and Ravenscourt Park hospitals together became a single virtual, filmless institution in April 2004.

Managing 24/7 reporting across the three sites prior to PACS/RIS/HIS integration was a timetabling challenge, due to the daily fluctuations in staffing at each location, said Dr. Nicola Strickland, a consultant radiologist at Hammersmith Hospitals NHS Trust. The Hammersmith and Charing Cross sites each generate about 100,000 radiology examinations per year, while the smaller Ravenscourt Park produces around 20,000. The three hospitals are served by 32 consultant (staff) radiologists and a number of specialty trainees. Junior radiologists also move regularly among London hospitals as they complete their training.

"It is vital that we provide as continuous a reporting service as possible," Strickland said. "PACS in a virtual hospital environment allows reporting to be completely site-independent and time-independent, and it distributes the workload more evenly."

Radiology reporting in the filmless hospital is now organized around a more flexible and self-accountable timetable. Fixed four-hour reporting sessions have been replaced with shorter blocks, and the working day extended to suit individuals' preferences. Timetabling overlaps help deal with unavoidable absences.

Detailed analysis of reporting turnaround before and after the workflow reengineering, using data gathered from the hospitals' RIS, reveals a marked improvement. Examinations from accident and emergency admissions or general practitioner referrals should ideally be reported and signed off within one working day, Strickland said. Fewer than 20% of A&E cases and just 30% to 50% of GP referrals at Charing Cross met that goal prior to PACS. Performance rose to about 85% and 75%, respectively, after the switch to filmless radiology.

All reporting work is now subject to continuous audit. A detailed breakdown of monthly performance circulates to all radiologists working within the virtual hospital, as a form of internal peer review.

"This transparency has encouraged a certain competitiveness among some radiologists to produce as much work as possible," Strickland said. "This is without any increase in pay."

Creation of a communal room for soft-copy reporting at the two larger hospital sites has provided additional incentive for radiologists to report, she said. Considerable attention has been paid to decor and furniture in the rooms to promote a positive working environment. Reporting booths, each containing a dual-monitor PACS workstation, are separated by soundproof screens to ensure privacy. But if individuals want a second opinion on a difficult case, they are likely to find a colleague at a nearby desk.

"Reporting is actually a very social activity," Strickland said. "We have also noticed that having a communal reporting room encourages interradiologist consultation."