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Radiology and EPR at the Brighton Radiology Visit

Anant Patel Lead Radiographer (CG/RPS/IT/Redesign). Mohmed Patel PACS Manager. Radiology and EPR at the Brighton Radiology Visit. Brighton Objectives. Visit EPR site with radiology integration (Anant) Radiology Information System (RIS)/PACS & Desk Top Integration (Mohmed)

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Radiology and EPR at the Brighton Radiology Visit

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  1. Anant Patel Lead Radiographer (CG/RPS/IT/Redesign) Mohmed Patel PACS Manager Radiology and EPR at the Brighton Radiology Visit Homerton University Hospital NHS Foundation Trust

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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

  7. Once Contract Signed.. • Current flows • Design Consultancy Sessions • Questionnaire • Future Flows • Making the design decisions Homerton University Hospital NHS Foundation Trust

  8. 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

  9. 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

  10. Questionnaire Contents • Order processing (Powerchart etc) • Order Entry Formats • Patient Labels • Cancel exams • Radiographer info • Radiology Report • Additional Information Homerton University Hospital NHS Foundation Trust

  11. 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

  12. Homerton University Hospital NHS Foundation Trust

  13. 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

  14. 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

  15. 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

  16. Radiographer Flows • 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

  17. Radiologist Flows • PACS centric flow • Use templates or VR to dictate • Sign immediately Homerton University Hospital NHS Foundation Trust

  18. 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

  19. Other Applications linked with Radiology (RIS/PACS) • 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

  20. PACS-EPR Homerton University Hospital NHS Foundation Trust

  21. 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

  22. Issues I- Technical • Support (in house very very limited resources)- • 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

  23. Issues II- Clinical • IRMER- • Workaround having schedulable to orders, i.e. vetting • Non Medical Referrers, Open Requesting Policy • 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

  24. 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

  25. 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

  26. 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

  27. 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

  28. Additional Benefits • 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

  29. Good • 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

  30. References • Patel, A., and P. Hogg. 2009. Cutting the Paper Chain. Synergy, September 1, 26-30.  http://www.proquest.com/ (accessed November 16, 2010) Homerton University Hospital NHS Foundation Trust

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