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Using informatics to improve

the quality of radiology


Web-based tools that are integrated in the PACS enable seamless
quality-control reporting, tailored technologist training, and
effective delivery of critical alerts to clinicians.

Paul G. Nagy, PhD

O
ne of the roles of an informatics can do a better job of using some of these don’t get feedback on the quality of
architect is to provide an infra- communication vehicles to create a cul- their work, they are likely to either think
structure that enables radiolo- ture of quality within radiology—to they’re doing a great job or that radiolo-
gists to read images immediately wher- make it easier to do the right thing while gists in their institution don’t care about
ever they are. Such rapid access to digi- being as productive as possible. This arti- image quality. Radiology supervisors
tal imaging reduces delays in interpreta- cle will discuss 3 tools we have devel- may know that radiologists are un-
tion, speeds report turnaround time, and oped at the University of Maryland to happy, but they have no data to use in
hastens clinical decision-making, all of enhance quality through informatics. taking action. The result is a disappoint-
which clearly improve efficiency. ing stalemate.
Over the years, however, it has be- Quality-control reporting Information technology systems must
come equally clear that an accelerated The first challenge many radiology be able to handle communications feed-
work pace, a focus on productivity, and practices face when they “go digital” is back to ensure quality processes. The key
the use of distance medicine can sterilize incorporating the quality-control prac- ingredients for change at the University of
work relationships. When a technologist tices that were used in the film environ- Maryland were a picture archiving and
no longer comes into the reading room ment. In the past, radiologists could note communications system (PACS) and a
to hang films, something gets lost in the on the film if the images were poorly simple Web-based issue tracking tool that
relationship between radiologist and collimated or were substandard in some enables radiologists to submit quality-
technologist. When referring physicians other way. In an electronic environment, control issues, assigns issues to owners,
no longer engage the radiologist in con- there is little feedback between radiolo- and notifies users when the issue has been
sultations, something gets lost in that gists and technologists. resolved. We also supplied our technolo-
relationship too. These changes threaten The result can be a downward spiral gists and modality supervisors with digital
to compromise quality. in quality. Often, radiologists submit pagers. When a radiologist reports a qual-
In our desire to leverage information quality-control reports using the same ity issue, the system pages the technolo-
technology (IT) to be as productive as paper-based forms they were using gist and modality supervisor immediately.
possible, we have threatened our work years ago. The reports go to modality To encourage radiologists to report
relationships. This doesn’t need to be so. supervisors, who discuss them with quality issues, it is important to remove
Essentially, IT was born to communicate, the technologists. But the radiologists as many barriers as possible and to
whether by voicemail, e-mail, text mes- typically don’t receive any feedback make reporting simple. With this in
saging, instant messaging, or paging. We on actions taken and don’t observe any mind, we synchronized quality control
improvement. As a result, it is difficult with our clinical workflow by adding a
Dr. Nag y is an Associate Professor, for radiologists to see the value in sub- button to our PACS that launches a
Director of Quality and Informatics mitting future quality-control reports. Web-based quality-control tool called
Research, Department of Radiology ,
Once radiologists become apathetic Radtracker1 (Figure 1).
Univ ersity of Mary land School of
Medicine, Baltimore, MD. about reporting quality issues, many The issue-submission Web page pro-
things can go awry. If technologists vides the user name, the study session

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INFORMATICS FOR QUALITY RADIOLOGY

A B

FIGURE 1. Radtracker synchronizes quality control (QC) with clinical workflow. (A) A button on the PACS launches the Web-based QC tool.
(B) The issue-submission Web page provides the user name, the study session number, the patient medical record number (MRN), and the
modality. (C) Within a single pull-down menu, the radiologist can select what is wrong with the images—poor patient positioning, for exam-
ple—and can add comments. When the radiologist clicks on “submit,” the modality supervisor and technologist receive a text message about
the issue and how to correct it. The technologist then resolves the issue, and the radiologist receives an e-mail about actions taken.

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even launch the PACS system simply by


clicking on a case file.
Every few months, a radiologist, tech-
nologist, modality supervisor, and physi-
cist meet for an hour to work through all
of the quality-control issues in a given
imaging section. This offers radiologists
an ideal opportunity to lead a discussion
on how quality-control issues arise. In
the past, our modality supervisors were
very good at fixing problems on a day-to-
day basis but didn’t necessarily under-
stand the magnitude of the issue. Now,
when they see that a problem is occur-
ring many times a year, they realize it’s
worth the effort to determine why the
problem is happening and how to re-
move the root causes.
We also use this system for generating
report cards (Figure 2). These report
cards enable our technologists to see
how well they’re doing, how many qual-
ity reports they’re getting from radiolo-
gists over a period of time, and how they
compare with other technologists. We
have found that most technologists are
very responsive. Once they see the data,
they try to understand how they can do a
better job. This is a very powerful tool
for creating a culture of quality.
FIGURE 2. Report cards enable technologists to see how well theyʼre doing, how many quality For radiologists, this system provides
reports theyʼre getting from radiologists over a period of time, and how they compare with
other technologists.
a mechanism to report quality issues and
removes any reason for being apathetic.
number, the patient medical record has enabled us to focus on the root cause We now have data-driven discussions
number, and the modality. Within a sin- of quality-control issues and to track with the radiologists to try to understand
gle pull-down menu, the radiologist can how quickly we respond to these issues. the root causes of quality issues. The
select what is wrong with the images— In approximately 40% of cases, we radiologists feel that the technologists are
poor patient positioning, for example resolve the issue within an hour. working with them, that we are a team,
—and can add comments. When the We have also uncovered new types of and that we have a good feedback mech-
radiologist clicks on “submit,” the mo- quality issues, beyond those related to anism and good communication.
dality supervisor and technologist re- image acquisition. Data quality issues
ceive a text message about the issue can affect the radiologist’s workflow. Technologist peer review
and how to correct it. The technologist For example, if the technologist doesn’t The second quality-control tool that
then resolves the issue, and the radiolo- sign off and complete a study in time, we have implemented, technologist peer
gist receives an e-mail about actions the radiologist might not be able to review, also harkens back to the days of
taken. finalize it. Using this process, we’re bet- film. Acquiring images has always been
Using this system, we have gone from ter able to understand problem areas in an art that requires training and feedback
approximately 5 to 10 paper-based qual- the department. to perfect. In the past, as senior film
ity-control reports per month in 2006 to We have used the quality-control data technologists processed films, they
300 per month today. This does not to create knowledge bases that we can would review images and take junior
reflect deterioration in quality; in fact, click through and explore. When we do technologists to task for quality prob-
only roughly 1% of our annual volume in-service training, we use the knowl- lems. Through peer pressure, junior
of studies has a quality-control issue. edge bases to find various types of cases. technologists would be motivated to
Instead, better quality-control reporting Using URL-based integration, we can improve their performance.

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Peer pressure is an enormous motiva-


A
tor that we don’t use well enough in
healthcare to improve performance. At
our institution, we use informatics as a
tool for applying peer pressure. We no
longer have the luxury of doing in-line
quality control while processing film.
Radiologists need to read images right
away and report them immediately.
However, we can do retrospective qual-
ity control.
To achieve this goal, we have built a
fully automated Web-based Tech Quality
Assurance (QA) tool that captures all the
studies done by a section, then randomly
assigns approximately 5% of them to a
volunteer to review (Figure 3). Review-
ing technologists are given a work list
with the procedure names and dates.
Because of synchronization between
information systems, they can launch the
study in the PACS system simply by
clicking on the integrated URL.
Once the study has been launched, the
technologist reviewer rates it on a scale of
1 to 5, with 1 being poor and 5 being
excellent. The ratings cover patient posi-
tioning, image clarity/artifacts, contrast,
annotations, markers, and radiation
B
safety. The reviews are then approved or
disapproved by a modality supervisor.
This step enables us to train our volun-
teers to become better reviewers.
We have used this technique to re-
view >5000 studies so far. We have
found that we’re doing well on contrast,
data quality, and annotations, but have
room for improvement in markers, posi-
tioning, and radiation safety (mostly col-
limation).
We can also use the Tech QA tool in
preparing individual technologist report
cards. This is a way of giving very tai-
lored feedback on how to improve their
processes. We can also use this tool as a
knowledge base to identify the best and
worst studies in each section, so that
technologists can learn by both doing
and seeing.
FIGURE 3. (A) A fully automated Web-based Tech QA tool captures all reports done by a sec-
tion, then randomly assigns approximately 5% of them to a volunteer to review. (B) The tech-
Communication
nologist reviewer rates each study on a scale of 1 to 5, with 1 being poor and 5 being excellent. Communication between radiologists
The ratings cover patient positioning, image clarity/artifacts, contrast, annotations, markers, and referring physicians plays another
and radiation safety. important role in quality. Take the case of

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When the radiologists launch the criti-


cal alert tool from our PACS, they are
presented with all of the patient informa-
tion and names of clinicians who have
been involved in patient care, along with
information on how old the contact data
are. Once we have all this information,
we mine a centralized physician contact
database with phone numbers and an
integrated online paging system. The
radiologist simply clicks on the “contact”
button next to each name.
In addition, we have built a blogging
tool that can be launched from the PACS
and documents all the radiologist’s
efforts to communicate critical findings,
as well as to document that it was suc-
cessfully delivered, to whom, and when.
FIGURE 4. To help in identifying the right person to receive information in critical situations, Healthcare IT systems are a gold mine
data mining tools identify who is involved in patient care. This tool can perform a real-time of information. If we can provide some
query of the electronic medical record [EMR] to determine where the patient is located, which
of that information in a relevant format to
service team is caring for the patient, and who has been in contact with the patient in the last
24 hours. The data mining tool can also look at the picture archiving and communications sys- radiologists, it can help them to make
tem [PACS] to see who has been viewing images, and at the computer-based physician order decisions and to communicate informa-
entry [CPOE] system to see who has been placing physician orders for the patient. A central- tion quickly in a critical environment.
ized physician contact database contains phone numbers and an integrated online paging
system. In addition, a blogging tool can be launched from the PACS to documents all of the
radiologistʼs efforts to communicate critical findings.
Conclusion
Communication plays a vital role in
a critical finding that warrants rapid com- patient care (Figure 4). This tool can per- how we deliver radiology services and
munication. The Joint Commission on form a real-time query of the electronic in the quality of those services. Infor-
the Accreditation of Healthcare Organi- medical record to determine where the mation technology is immensely quali-
zations (JCAHO) requires that radiolo- patient is located and which service fied to deliver tools that improve quality
gists document not only that a critical team is caring for the patient. Often, it is and communications. The time has
finding has been delivered but also how more important to identify the appropri- come for radiologists to insist that ven-
long it took to deliver the finding. ate service team than to identify the indi- dors provide these tools. PACS stands
Delivery of critical findings can be vidual physician. for picture archiving and communica-
especially challenging in a large in- We can also use the critical alert tool tion system. It’s time to put the commu-
patient medical center. At the University to determine who has been in contact nication back in PACS.
of Maryland, we have roughly 1100 with the patient in the last 24 hours.
attending physicians and another 900 Knowing which physicians and nurses REFERENCE
1. Nagy PG, Pierce B, Otto M, Safdar NM. Quality
residents. Often the physician who are giving care to the patient offers an control management and communication between
orders a study is not the right person to important clue in determining to whom radiologists and technologists. J Am Coll Radiol.
take delivery of the critical finding. This to deliver critical information. We can 2008;5:759-765.
is a source of frustration for radiologists. also look at the PACS to see who has been
To help in identifying the right person looking at the images and the computer-
For a roundtable discussion of this article,
to receive information to critical situa- based order entry system to see who visit http://www.appliedradiology.com/
tions, we have developed data mining has been placing physician orders for informatics.
tools that identify who is involved in the patient.

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