Download The Imaging Value Chain

The Imaging Value Chain
Delivering Appropriateness, Quality,
Safety, Efficiency and Patient
Satisfaction
Giles W.L. Boland, MD,
Massachusetts General Hospital
Harvard Medical School
Goals
Rules
• Outline drivers in new healthcare
paradigm
• Volume to value
• Why we need to change
• Tools to deliver a different kind of value
• Based on concept of the value chain
Old World
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Performance based on volume
Fee for service
Volume = incomes
System geared towards high costs
Radiologists benefited
Outcomes variable
Too costly?
Value for Money?
Life expectancy
Life expectancy
79.5
11.2
New World
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Need to measure outcomes
Payments decided upon them
System geared towards saving costs
Fee for value
Outcomes = incomes
Need to know how to deliver outcomes
Intimately related to value
New World
• Outcomes
• Value
• Cost
Value = outcomes
cost
Redesign to Deliver Value
• Integrated practice unit
• Measure outcomes for every
patient
• Bundled payments and care cycles
• Integrate care delivery cycles
• Expand geographic reach
• Build an enabling technology
platform
Measure Outcomes and Cost
for Every Patient
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The outcome hierarchy
Measured by medical condition
Tier 1 - health status achieved
Tier 2 - care cycle and recovery
Tier 3 – health sustainability
Costs go down as each tier improves
Porter et al.
Measuring the Wrong Metrics
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Processes
Some form of quality but not outcomes
Volume (RVUs)
Modality throughput
Report turnaround time
Recommendation field
Revenue
Healthcare
RulesReform
• Patient value and outcomes
• Payments dependent on new metrics
• 65 measures in 5 domains (32 quality
goals) – risk based
1. Patient experience
2. Care coordination
3. Patient Safety
4. Preventative health
5. Health of at risk and elderly patients
Value
Value
• A fundamental change in the way we
operate
• Mostly a mindset transformation
• Once the mindset is changed we are
open to looking, changing and improving
• Doesn’t happen overnight – long haul
• Be engaged and transform your product
• Everyone must be engaged
Old World
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Not so profitable anymore
DRA, bundling, utilization rate, SGR
Incomes down
What has been our response?
Red Queen Effect
Red Queen Effect
Not a sustainable strategy
Imaging
Rules 3.0
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5 pillars
Appropriateness
Quality
Safety
Efficiency
Patient satisfaction
Imaging
Rules 3.0
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5 pillars
Appropriateness
Quality
Safety
Efficiency
Patient satisfaction
Why – because health care delivery
has changed and new drivers
So how do we respond?
• Radiology must adapt to the value dynamic
• Design best practice care pathways
• Develop and implement standardized best
practices
• Reduce variation
• Variation = error = waste = cost
• Reducing waste improves outcomes
• Key to delivery is the Imaging Value Chain
Value Chain
• Michael Porter 1985 (HBS)
• “A systematic way of examining all the
activities a firm performs and how they
interact is necessary for analyzing the
sources of competitive advantage. In this
chapter, I introduce the value chain as the
basic tool for doing so”
Value Chain
• Any business has a value chain
• Each link has bundle of activities (value
activities)
• Each link can be changed/improved
• Key to delivering value is addressing EVERY
aspect of the chain
• Evaluate + re-engineer each link in the
chain to enhance value in aggregate
• Reduce waste (error and cost)
• Improve patient experience and outcomes
Radiology Value Chain
Desk-top
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Distribution
• Routine
• Urgent
• Critical
Protocol
Scheduling
Image appropriateness
Utilization
Decision Support
Exam Time and Location
Pre-procedure process
Reporting
• Data mining
• Ontology-Standard templates
• Decision support
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Imaging Technology
Anatomic
Functional
Physiological
Procedure
• Customized service
• Patient preference
• Throughput
A value chain is a chain of activities that an industry performs to deliver a
valuable product or service (Michael Porter)
Radiology Value Chain
Desk-top
Actionable
Report
Distribution
• Routine
• Urgent
• Critical
Protocol
Scheduling
•
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Image appropriateness
Utilization
Decision Support
Exam Time and Location
Pre-procedure process
Reporting
• Data mining
• Ontology-Standard templates
• Decision support
•
•
•
•
Imaging Technology
Anatomic
Functional
Physiological
Procedure
• Customized service
• Patient preference
• Throughput
A value chain is a chain of activities that an industry performs to deliver a
valuable product or service (Michael Porter)
Radiology Value Chain
Desk-top
Actionable
Report
Distribution
• Routine
• Urgent
• Critical
Protocol
Scheduling
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Image appropriateness
Utilization
Decision Support
Exam Time and Location
Pre-procedure process
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Imaging Technology
Anatomic
Functional
Physiological
Information Business
Reporting
• Data mining
• Ontology-Standard templates
• Decision support
Procedure
• Customized service
• Patient preference
• Throughput
A value chain is a chain of activities that an industry performs to deliver a
valuable product or service (Michael Porter)
Radiology Value Chain
Desk-top
Actionable
Report
Distribution
• Routine
• Urgent
• Critical
Scheduling
Protocol
• Image appropriateness
• Imaging Technology
• Utilization
Standard text/ontology
• Anatomic
• Decision
Support reporting (succinct)
• Functional
Structured
• Exam Time and Location
• Physiological
Incorporates
collateral
biomarker
data
• Pre-procedure process
Data mining
Reporting
• Data mining
• Ontology-Standard templates
• Decision support
Procedure
• Customized service
• Patient preference
• Throughput
A value chain is a chain of activities that an industry performs to deliver a
valuable product or service (Michael Porter)
Radiology Value Chain
Desk-top
Actionable
Report
Distribution
• Routine
• Urgent
• Critical
Protocol
Scheduling
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Image appropriateness
Utilization
Decision Support
Exam Time and Location
Pre-procedure process
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Imaging Technology
Anatomic
Functional
Physiological
Impacts Patient Outcomes
Reporting
• Data mining
• Ontology-Standard templates
• Decision support
Procedure
• Customized service
• Patient preference
• Throughput
A value chain is a chain of activities that an industry performs to deliver a
valuable product or service (Michael Porter)
Radiology Value Chain
ERROR
PERVADES
VALUE CHAIN
Desk-top
Actionable
Report
Distribution
• Routine
• Urgent
• Critical
Protocol
Scheduling
•
•
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•
Image appropriateness
Utilization
Decision Support
Exam Time and Location
Pre-procedure process
Reporting
• Data mining
• Ontology-Standard templates
• Decision support
•
•
•
•
Imaging Technology
Anatomic
Functional
Physiological
Procedure
• Customized service
• Patient preference
• Throughput
A value chain is a chain of activities that an industry performs to deliver a
valuable product or service (Michael Porter)
Radiology Value Chain
Desk-top
Actionable
Report
Error
• Routine
• Urgent
• Critical
Error
Error
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Image appropriateness
Utilization
Decision Support
Exam Time and Location
Pre-procedure process
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Imaging Technology
Anatomic
Functional
Physiological
Report is not
ACTIONABLE
Affects Outcomes
Error
• Data mining
• Ontology-Standard templates
• Decision support
Error
• Customized service
• Patient preference
• Throughput
A value chain is a chain of activities that an industry performs to deliver a
valuable product or service (Michael Porter)
Where are we Now?
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Variation
Suboptimal performance
Increased error
Increased waste
Increased cost
Reduced value and outcomes
Radiology Value Chain
Desk-top
Actionable
Report
Distribution
• Routine
• Urgent
• Critical
Protocol
Scheduling
•
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•
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•
Image appropriateness
Utilization
Decision Support
Exam Time and Location
Pre-procedure process
Reporting
• Data mining
• Ontology-Standard templates
• Decision support
•
•
•
•
Imaging Technology
Anatomic
Functional
Physiological
Procedure
• Customized service
• Patient preference
• Throughput
A value chain is a chain of activities that an industry performs to deliver a
valuable product or service (Michael Porter)
Map shows states according to radiology utilization quartiles
based on number of procedures per 1000 Medicare enrollees.
Bhargavan M , Sunshine J H Radiology 2005;234:824-832
©2005 by Radiological Society of North America
Map shows states according to radiology utilization quartiles
based on number of procedures per 1000 Medicare enrollees.
> 50% variation in utilization
Bhargavan M , Sunshine J H Radiology 2005;234:824-832
©2005 by Radiological Society of North America
New World
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Outcomes
Value
Cost
Appropriateness (A)
Value = A x outcomes
cost
Richard Duszak
New World
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Outcomes
Value
Cost
Appropriateness (A)
Value = 0 x outcomes
cost
New World
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Outcomes
Value
Cost
Appropriateness (A)
Value = 0
Radiology Value Chain
Desk-top
Actionable
Report
Distribution
• Routine
• Urgent
• Critical
Protocol
Scheduling
•
•
•
•
•
Image appropriateness
Utilization
Decision Support
Exam Time and Location
Pre-procedure process
Reporting
• Data mining
• Ontology-Standard templates
• Decision support
•
•
•
•
Imaging Technology
Anatomic
Functional
Physiological
Procedure
• Customized service
• Patient preference
• Throughput
Protocoling
• Dose (all over the map)
• Too many protocols? (368 CT at MGH)
• Protocols vary from one radiologist to
another (whose right?)
• Radiologist du jour (keeps techs
guessing)
• MRI Abdomen 20 min to 1.5 hours
• What does the patient think?
Radiology Value Chain
Desk-top
Actionable
Report
Distribution
• Routine
• Urgent
• Critical
Protocol
Scheduling
•
•
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Image appropriateness
Utilization
Decision Support
Exam Time and Location
Pre-procedure process
Reporting
• Data mining
• Ontology-Standard templates
• Decision support
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•
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•
Imaging Technology
Anatomic
Functional
Physiological
Procedure
• Customized service
• Patient preference
• Throughput
Modality Efficiency
How productive?
How busy is busy?
Patient wait-times
Procedure slot length (MRI 15 min to 1
hour)?
• Hours of operation?
• Weekends?
• How many technologists?
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Radiology Value Chain
Desk-top
Actionable
Report
Distribution
• Routine
• Urgent
• Critical
Protocol
Scheduling
•
•
•
•
•
Image appropriateness
Utilization
Decision Support
Exam Time and Location
Pre-procedure process
Reporting
• Data mining
• Ontology-Standard templates
• Decision support
•
•
•
•
Imaging Technology
Anatomic
Functional
Physiological
Procedure
• Customized service
• Patient preference
• Throughput
A value chain is a chain of activities that an industry performs to deliver a
valuable product or service (Michael Porter)
Interpretation Variability
• Abdominal and pelvic CT interpretation:
discrepancy rates amongst experienced
radiologists (Abujudeh et al, European
Radiology)
• Major discrepancies (missed findings,
different conclusions of interval change,
presence of recommendations)
• Interobserver error 26%
• Intraobserver error 32%
Recommendations
• Incidental findings common
• 21% CTs generate recommendations for
further imaging (Sistrom et al)
• Too many inconsistencies for
recommendations
Recommendation Rates: LS-MRI
Courtesy Pragya Dang
MD
Recommendation Rates: LS-MRI
33%
Courtesy Pragya Dang
MD
7%
Recommendations – Abdominal Division
There were 24 radiologists who interpreted 25,412 CT examinations
Aaa
Fellows 45%
Average Recommendation Rates
\
45.0%
Aaa
aaa
aaa
a
40.0%
35.0%
Junior 30%
30.0%
Intermediate 23%
25.0%
Senior 21%
20.0%
15.0%
10.0%
5.0%
0.0%
Clinical Fellows
Junior Radiologists
Intermediate Radiologists
Senior Radiologists
Report Structure- Free text
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REPORT:
This study was reviewed with Dr. XXXXX
Abdominal-pelvic CT following the administration of oral and IV
contrast was conducted as per departmental protocol. This study
was conducted to determine the presence of metastasis from
pancreatic ca. The study was extended into the pelvis to
determine the presence of pelvic lymphadenopathy.
Comparison is made to the previous study dated 7/22/99
There has been interval increase in the size and number of
multiple pulmonary nodules.
There is stable pneumobilia from a prior nipple procedure. There
is a single large hepatic metastasis within the right lobe of the
liver measuring 7.2 cm by 6.5 cm. This previously measured 4.5 cm
by 4.8 cm
There is a right renal cyst which remains unchanged. There is a
soft tissue density between the portal vein and superior
mesenteric vein which remains stable from the previous study and
likely represents post operative change, however metastasis cannot
be excluded. There is a new para-aortic lymph node measuring 7 mm
surrounding surgical clips. There is a small 9 mm retrocrural
lymph node which is more prominent than the previous study. The
prostate gland is enlarged. The remainder of the spleen, adrenal
glands, kidneys and bowels are unremarkable.
Report Structure- Free text
.
REPORT:
This study was reviewed with Dr. XXXXX
Abdominal-pelvic CT following the administration of oral and IV
contrast was conducted as per departmental protocol. This study
was conducted to determine the presence of metastasis from
pancreatic ca. The study was extended into the pelvis to
determine the presence of pelvic lymphadenopathy.
Comparison is made to the previous study dated 7/22/99
There has been interval increase in the size and number of
multiple pulmonary nodules.
There is stable pneumobilia from a prior nipple procedure. There
is a single large hepatic metastasis within the right lobe of the
liver measuring 7.2 cm by 6.5 cm. This previously measured 4.5 cm
by 4.8 cm
There is a right renal cyst which remains unchanged. There is a
soft tissue density between the portal vein and superior
mesenteric vein which remains stable from the previous study and
likely represents post operative change, however metastasis cannot
be excluded. There is a new para-aortic lymph node measuring 7 mm
surrounding surgical clips. There is a small 9 mm retrocrural
lymph node which is more prominent than the previous study. The
prostate gland is enlarged. The remainder of the spleen, adrenal
glands, kidneys and bowels are unremarkable.
Where’s the Actionable data?
Radiology Value Chain
Desk-top
Actionable
Report
Distribution
• Routine
• Urgent
• Critical
Protocol
Scheduling
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•
•
Image appropriateness
Utilization
Decision Support
Exam Time and Location
Pre-procedure process
Reporting
• Data mining
• Ontology-Standard templates
• Decision support
•
•
•
•
Imaging Technology
Anatomic
Functional
Physiological
Procedure
• Customized service
• Patient preference
• Throughput
Report Communication
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Electronic?
On EMR
Important findings alert
Documented in report?
Critical findings alert
Closing the loop
F/u for important recommendations
Radiology Value Chain
ERROR
PERVADES
VALUE CHAIN
Desk-top
Actionable
Report
Distribution
• Routine
• Urgent
• Critical
Protocol
Scheduling
•
•
•
•
•
Image appropriateness
Utilization
Decision Support
Exam Time and Location
Pre-procedure process
Reporting
• Data mining
• Ontology-Standard templates
• Decision support
•
•
•
•
Imaging Technology
Anatomic
Functional
Physiological
Procedure
• Customized service
• Patient preference
• Throughput
A value chain is a chain of activities that an industry performs to deliver a
valuable product or service (Michael Porter)
Radiology Value Chain
Desk-top
Actionable
Report
Error
• Routine
• Urgent
• Critical
Error
Error
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Image appropriateness
Utilization
Decision Support
Exam Time and Location
Pre-procedure process
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Imaging Technology
Anatomic
Functional
Physiological
Report is not
ACTIONABLE
Affects Outcomes
Error
• Data mining
• Ontology-Standard templates
• Decision support
Error
• Customized service
• Patient preference
• Throughput
A value chain is a chain of activities that an industry performs to deliver a
valuable product or service (Michael Porter)
Imagine Banking as Medicine
Radiology Value Chain
Desk-top
Actionable
Report
Distribution
• Routine
• Urgent
• Critical
Protocol
Scheduling
•
•
•
•
•
Image appropriateness
Utilization
Decision Support
Exam Time and Location
Pre-procedure process
Reporting
• Data mining
• Ontology-Standard templates
• Decision support
•
•
•
•
Imaging Technology
Anatomic
Functional
Physiological
Procedure
• Customized service
• Patient preference
• Throughput
A value chain is a chain of activities that an industry performs to deliver a
valuable product or service (Michael Porter)
Radiology Value Chain
Desk-top
Actionable
Report
Distribution
• Routine
• Urgent
• Critical
Protocol
Scheduling
•
•
•
•
•
Image appropriateness
Utilization
Decision Support
Exam Time and Location
Pre-procedure process
Reporting
• Data mining
• Ontology-Standard templates
• Decision support
•
•
•
•
Imaging Technology
Anatomic
Functional
Physiological
Procedure
• Customized service
• Patient preference
• Throughput
Scheduling: Precise Utilization
• Meeting societal expectations for safety and
efficiency
• Unnecessary imaging adds cost to the health
system and increases radiation burden and
other risks to patients
• Utilization should be guided by evidence
based appropriateness criteria (i.e. ACR
Appropriateness Criteria)
• Use of computer based point-of-care decision
support for ordering physicians is a promising
approach for managing utilization
Scheduling: Precise Utilization
• Meeting societal expectations for safety and
efficiency
• Unnecessary imaging adds cost to the health
system and increases radiation burden and
other risks to patients
Precision
Imaging
• Utilization should be guided by evidence
right
imaging,
right time,
patient
based
appropriateness
criteriaright
(i.e. ACR
Appropriateness Criteria)
• Use of computer based point-of-care decision
support for ordering physicians is a promising
approach for managing utilization
Radiology Value Chain
Desk-top
Actionable
Report
Distribution
• Routine
• Urgent
• Critical
Protocol
Scheduling
•
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•
•
•
Image appropriateness
Utilization
Decision Support
Exam Time and Location
Pre-procedure process
Reporting
• Data mining
• Ontology-Standard templates
• Decision support
•
•
•
•
Imaging Technology
Anatomic
Functional
Physiological
Procedure
• Customized service
• Patient preference
• Throughput
Protocol Selection
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Remove variance (dose)
Leadership - Insist on consistency
Across departments, institutions
Perhaps nationally (ACR?)
Best practice Protocol Management
Decision Support
Integrate collateral clinical data
Radiology Value Chain
Desk-top
Actionable
Report
Distribution
• Routine
• Urgent
• Critical
Protocol
Scheduling
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Image appropriateness
Utilization
Decision Support
Exam Time and Location
Pre-procedure process
Reporting
• Data mining
• Ontology-Standard templates
• Decision support
•
•
•
•
Imaging Technology
Anatomic
Functional
Physiological
Procedure
• Customized service
• Patient preference
• Throughput
Modality Management
Lean
Flow-chart operations
Hours of operation
Divide inpatient from outpatients
(different businesses)
• Technologist management
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Lean
• The endless transformation of waste
into value from the customer’s
perspective
• Value is any action or process that the
customer is willing to pay for
• Becoming more efficient based on
optimizing flow
Lean
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Tools to identify and eliminate waste
Production time and cost reduced
Quality improves
Getting the right things to the right
place at the right time in the right
quantity, while minimizing waste (and
being flexible and able to change)
Value stream mapping
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Mapping, identification and elimination of waste
Identify target (i.e. CT operations)
Map process
Identify waste
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Defects
Over Production
Transportation
Waiting
Inventory
Motion
Processing
Under Utilization Employee Creativity
Flowcharting
OUTPATIENTS
RSR prints
confirmation list and
calls Patients
two days prior to
scheduled CT
appointment.
INPATIENTS
Requisitions brought
from Blossom Court
Service Center and
filed according to
scheduled time
Inpatient tracking
forms and
requisitions are
placed in CT2
RSR sets printers to
print transportation
notices and tracking
forms the night prior
to Patient arrival
Failure Point: Restocking
too time consuming on the
morning of Patient
appointment.
Solution: Night RSR to
restock for the following
day.
Failure Point: Printing
Tracking forms on day of
Patient appointment is a time
consuming process.
Solution: Print, sort,
combine all tracking forms
with requisition the night
prior to Patients' arrival
RSR stocks
refrigerator with
barium & juice. Makes
sure straw and cup
supply filled
Morning RSR arrives
in CT
RSR makes sure that
dressing rooms clean
and linens are
stocked
RSR prints tracking
forms for the entire
day's scheduled CT
appointments
Daily schedules are
printed and separated
by area
Schedules are placed in
RSR area, RT area,
and all exam rooms
Tech sorts through
requisitions and
determines which
patients need Gastro
orders
Failure Point: Time
consuming to do on morning
of Patient appointment
Solution: Night RSR should
restock after last outpatient
departs.
Tracking forms are
separated into inpatient
and outpatient files.
Forms are then sorted
by modifiers.
Failure Point: Not
documenting time of Patient
arrival
Solution: Write down time
of patient arrival on
requisition form
Does the patient
need Gastro?
Failure Point: Patient Transport is
often short-staffed. Frequent delays
occur in bringing Patients to CT.
Ex: Slow reactions delay potential
opportunities when PR slot becomes
available.
Solution: Pilot a dedicated Patient
Transporter for CT to facilitate
Patient Transport.
Tracking forms are
combined with Patient
requisition and are filed
by Patient appointment
time
Failure Point: Not
protocolled in IDX. Time
consuming to track down
MD, lost reqs,etc.
Solution: Protocol exams in
evenings.
Exam scheduled,
paperwork printed,pt
arrived in IDX, no appt
time will be assigned
Referring physician
must call/send/fax
request to CT
RSR must call patient
referring physician for
request
No
Yes
Call floor 1/2 hour
before scanner
available to prepare
patient for CT scan
Tell floor to
administer Gastro
1-3 hours prior to
patient exam
Nurse writes time that
Gastro was started on
Gastro form
Nurse places Gastro
order form in
Inpatient chart
Radiologist is paged
to monitor injection
Radiologist arrives
and injection begins
No
Failure Point: Patient not
ready to be transported to CT
when Transport arrives.
Solution: Enforce
communication between Tech
and Patient Nurse.
Call patient transport
1/2 hour before
scanner available to
bring Patient from
floor to scanner
RT sorts through
tracking forms and finds
exams that are not
protocolled
Tech places
transportation notice
in bin outside scanner
2 door
RT must call
Radiologist to get
proper exam protocol
Transporter and
Patient arrive in Blake
2 CT
Transporter arrives
Patient in IDXRad
Outpatient arrives in
CT
RSR speaks with tech.
to make sure can fit
appointment into
schedule
Failure Point: Hand delivering
Gastro orders takes needed
resoruce(s) away from CT
Solution: Gastro orders
should be available on the
Patient floors so that when
Gastro is needed, nurse can fill
out form and place it in Patient
chart. For order entry floors,
should have Gastro form linked
to CT order form.
Tech fills out Gastro
orders for all
requisitions for that
day
Tech assistant makes
trip, twice daily, to all
floors to hand deliver
Gastro orders
Transporter gives
Patient chart and
transport notice to
Tech in scanner 2
Does Patient
have scheduled
appointment?
Yes
Tech looks at BUN &
Creatinine values in
Patient chart
RSR asks patient for
MGH blue card
Yes
RSR pulls filed
tracking form and
requisition
Are results
clinically valid for
CT exam?
No
Patient bloods drawn
in CT. Blood sent to
lab. Results available
w/in 30 min.
Yes
RSR arrives patient in
IDXRad
Page Radiologist
Are BUN and
Creatinine values
within normal limits?
No
RSR stamps blue card
imprint on tracking
form by addresograph
Failure Point: Elevated
Patient wait times may cause
aggravation and frustration
Solution: Initiate customer
service initiatives: 1) Water
bubbles 2) Newspapers 3)
Parking Vouchers 4) Gift
Certificates to Coffee Central
RSR asks patient to
fill out history form in
the waiting room
Failure Point: RSR
becomes busy in front of
Patients and is unavailable
to check queue
Solution: RT should
proactively take
requisitions from RSR area
Patient returns history
form to RSR
RSR checks Patient
queue in RT area.
No
Does the Patient
need to drink
contrast?
Yes
Present requisition
placed into RSR
queue.
RSR gives patient
contrast to drink
depending on
protocol (one hour
prior to exam)
Are there more
than four requisitions
in RT's queue?
Yes
No
Patient returns to
waiting room
Is there an
available seat in ante
waiting room?
No
Yes
Yes
Failure Point: Patients
arrive too early or too late for
appt. and are palced ahead
in queue of those who
should be first.
Solution: RSRs should
write pt. arrival time on
tracking form and filed first
by appt. time, then by arrival
time.
RSR brings Patient
into changing room
RSR files req. and
tracking form in RT
bin, filed by
appointment time
When Patient is
changed, s/he takes
seat in holding area
IV CONTRAST
Does Patient
need IV?
Yes
Exam is begun in
IDXRad
Patient is brought to
IV staging area
Patient bloods drawn
in CT. Blood sent to
lab. Results available
w/in 30 min.
Is pt. between
18-50 with no history of
heart disease, multiple
myeloma, or renal
disease?
No
Are lab values
(BUNS, creatinines)
known?
No
Yes
Yes
RSR must call 4-LABS
to access pt. BUN and
Creatinine values
Are results clinically
valid for CT exam?
No
Page Radiologist.
Yes
Nurse attempts to
place IV
No
Radiology Nurse is
called
Is
Radiology
Nurse
successful?
Is Nurse
Successful?
(3 stick max.)
No
Yes
Yes
No
IV Nurse Team is
called for help
IV Nurse Team places
IV
Nurse documents on
tracking form the time
of IV placement
Is Patient having
an abdomen/pelvis
scan?
No
Patient is not given
oral contrast
Yes
Patient is given oral
contrast to drink five
minutes prior to scan
Patient remains
seated/lying down in
holding area until
scanner becomes
available
INPATIENT
SCANNER
OUTPATIENT
SCANNER
Failure Point: Improperly
require techs to reschedule
exams.
Solution: More thorough
Patient histories required.
Tech 1 enters Patient/
exam information into
logbook
Tech 2 loads power
injector
Tech 1 enters patient
information into
scanner
Tech 2 brings Patient
into exam room and is
positioned on table
Tech 2 verifies history
with Patient and
explains procedure
Scanning is begun
Failure Point: Radiologist
delays in responding to
calls. Increases pt.
throughput time.
Solution: Commitment
from division heads to
make sure that
radiologists are available
at all times.
Tech 2 connects
power injector to
Patient IV
Tech 1 sets up scout
parameters and scans
scout
Does Patient have
contraindications?
Scan parameters are
entered into system
Yes
Radiologist is paged
to monitor injection
Tech 1 enters Patient
information into
scanner
Tech 2 brings Patient
into exam room and is
positioned on table
Tech 1 begins exam in
IDXRad
Tech 2 verifies history
with Patient and
explains procedure
Tech 1 enters Patient/
exam information into
logbook
Tech 2 verifies history
with patient and
explains procedure
Scanning is begun
Tech 2 connects
power injector to
Patient IV
Tech 1 sets up scout
parameters and scans
scout
Radiologist arrives
and injection begins
Does Patient have
contraindications?
Yes
No
No
Study images are
acquired
Images are deemed
accepatable
Scan parameters are
entered into system
Tech 2 stays in room
to monitor injection
Failure Point: No
designated area or team to
provide pt. monitoring.
Solution: Residents and
fellows take responsibility
for monitoring pt. until
crisis point passes.
Failure Point: Patient
Transport is often delayed
and patients are left in
hallway unattended.
Solution: Establish
dedicated tranporter for CT.
Patient is monitored
after exam to make
sure no adverse
reactions occur
Anaphylactic
Tech 1 goes to Relay/
QC Station
Does Patient have
contrast reaction?
Yes
Study images are
acquired
Tech 2 stays in room
to monitor injection
Patient is monitored
after exam to make
sure no adverse
reactions occur
Treat for reaction
Anaphylactic
Treat for reaction
Tech 1 calls Patient
Transport to have
Patient returned to
floor
Is reaction
anaphylactic or
extravization?
Tech 1 deems images
accepatable
Does pt. have
contrast reaction?
No
No
Correct information
so that patient AN and
MRN match
No
Is the study
verified?
Segment Study
Yes
Does Study
need to be
segmented?
Yes
No
Extravization
Place second I.V.
Tech 1 Completes the
Patient in IDXRad
Patient leaves room
and exits CT
department
Failure Point:
1. Techs may fail to segment
studies that require this step.
2. Techs may segment study, but
not saved by software when
transmitted to PACS
Solution:
1. Reinforce and manage training/
retraining, communications.
2. Phase in better software that
allows multiple AN under each MRN.
Tech 1 goes to Relay/
QC Station
Correct information
so that patient AN and
MRN match
No
Is the study
verified?
Segment Study
Yes
Does study need
to be segmented?
Transmit studyt to
PACS/AMICAS
Verify Study
transmission and
proper routing using
Check PACS Website
Tech Completes and
Departs Patient in
IDXRad
Tech 2 takes Patient
off of table
Tech 2 brings in next
Patient
Patient Transport
arrives in CT
Yes
Failure Point: Techs may not
do this step because feel it is
too time consuming
Solution: More sophisticated
software which allows multiple
ANs to be assigned to one
MRN.
No
Transmit study to
PACS/AMICAS
Failure Point: Study does
not immediately show up to
confirmation in Check PACS
website. May have a delay
of up to 20 minutes.
Solution: Better software
which allows multiple ANs.
Verify Study
transmission and
proper routing using
Check PACS Website
Patient Transport
Departs the Patient in
IDXRad and returns
Patient to floor
Yes
Is reaction
anaphylactic or
extravization?
Extravization
Place second I.V.
• 85
steps involved in
performing
outpatient CT exam
• 72 step process for
inpatient exams.
•Mapping improved
productivity by 11%
Modality Management
•
•
•
•
Flowchart operations
Parallel work process
3 techs at peak
Scale to expected
volume
1,2 and 3 tech models for CT
Tech 1
Patient chart is brought to CT Tech /tech calls patient
x
Patient Identification performed with exam verification
x
Patient's screening form is reviewed with patient
x
Patient is taken to changing area and changed
x
Examination explained to patient
x
Patient is given oral contrast if needed.
Patient escorted to IV prep area
IV access established outside scan room
Patient guided to bathroom prior to scan
Patient escorted to scanner
Patient placed on scanner table
IV connected to power injector
Tech 2
x
x
x
x
x
x
x
Exam inquiry in RIS performed for prior history
Patient weight and tech initials put into scanner
Logbook entry (paper copy)
Scout
Scans performed
Post processing task- Reformatting
Archive exam
Network images to relay
End exam
x
x
x
x
x
x
x
x
x
Patient helped off table
IV removed if necessary
Patient escorted to changing area
Tech prepares CT room for next patient
Power injector loaded
Room made ready for next patient
RIS completion of study and patient departure
Relay queried to confirm image transmission
Segment study if necessary
Study pushed to PACS
Place patient chart in patient completion bin
Confirm images arrived in PACS
Print film of study if necessary
Tech 3
x
x
x
x
x
x
x
x
x
x
x
x
x
Modality Management
Scheduled
Techs
Slot time
(minutes)
Patients/hr
Exams/hr.
1
26
2
3
2
12
5
7
2-3
8
7
10
Radiology Value Chain
Desk-top
Actionable
Report
Distribution
• Routine
• Urgent
• Critical
Protocol
Scheduling
•
•
•
•
•
Image appropriateness
Utilization
Decision Support
Exam Time and Location
Pre-procedure process
Reporting
• Data mining
• Ontology-Standard templates
• Decision support
•
•
•
•
Imaging Technology
Anatomic
Functional
Physiological
Procedure
• Customized service
• Patient preference
• Throughput
Precise Reporting
•
•
•
•
•
Use ALL information/data possible
Electronic medical record
Collateral clinical information
Image data extraction (3D, CAD)
Prior reports
Point of care data mining Integration
cancer
Courtesy M. Zalis
86
Precise Reporting
•
•
•
•
•
•
•
•
Synthesize data into meaningful report
Concise, clear, critical
Standard language
Ontology (standing vs. inflammation)
Essential for disease cohort research
Templates
Hyperlinks to key image findings
Recommendations
Standardized Templates
HISTORY:
TECHNIQUE:
CT of the abdomen WITH intravenous contrast.
COMPARISON: None available.
FINDINGS:
LOWER THORAX: Normal.
HEPATOBILIARY: No focal hepatic lesions. No biliary ductal dilatation.
SPLEEN: No splenomegaly.
PANCREAS: No focal masses or ductal dilatation.
ADRENALS: No adrenal nodules.
KIDNEYS: No hydronephrosis, stones, or solid mass lesions.
PERITONEUM / RETROPERITONEUM: No free air or fluid.
LYMPH NODES: No lymphadenopathy.
VESSELS: Unremarkable.
GI TRACT: Visualized portions of the bowel demonstrate no distention or wall thickening.
BONES AND SOFT TISSUES: Unremarkable.
IMPRESSION:
RECOMMENDATIONS:
Standardized Templates
HISTORY:
TECHNIQUE:
CT of the abdomen WITH intravenous contrast.
COMPARISON: None available.
FINDINGS:
LOWER THORAX: Normal.
HEPATOBILIARY: No focal hepatic lesions. No biliary ductal dilatation.
SPLEEN: No splenomegaly.
PANCREAS: No focal masses or ductal dilatation.
ADRENALS: No adrenal nodules.
KIDNEYS: No hydronephrosis, stones, or solid mass lesions.
PERITONEUM / RETROPERITONEUM: No free air or fluid.
LYMPH NODES: No lymphadenopathy.
VESSELS: Unremarkable.
GI TRACT: Visualized portions of the bowel demonstrate no distention or wall thickening.
BONES AND SOFT TISSUES: Unremarkable.
IMPRESSION:
RECOMMENDATIONS:
Radiology Value Chain
Desk-top
Actionable
Report
Distribution
• Routine
• Urgent
• Critical
Protocol
Scheduling
•
•
•
•
•
Image appropriateness
Utilization
Decision Support
Exam Time and Location
Pre-procedure process
Reporting
• Data mining
• Ontology-Standard templates
• Decision support
•
•
•
•
Imaging Technology
Anatomic
Functional
Physiological
Procedure
• Customized service
• Patient preference
• Throughput
Stat Scheduling and Reporting
STAT PROCESS
Reading STAT Exams
STAT exam is
completed by
technologist
Technologist calls
Division to notify
them that a STAT
is completed
Monday-Friday
8-5?
YES
Thoracic: 4-4213 (Dodd receptionist)
MSK: 3-3621 (Division Secretary)
Pedi: 4-4207 (Division Secretary)
Abdominal: 4-4213 (Dodd receptionist)
Emergency Neuro Rad: 3-2535 (inpt. beeper that
rolls over to x39991 on night and weekends)
NO
NagMe will also be
activated at the
workstations 24/7
Emergency Radiology: 4-1533
Emergency Neuro Rad: 3-2535 (inpt. beeper that
rolls over to x39991 on night and weekends)
Radiologist expected to
call referring physician
as soon as report is
preliminarily read.
Courtesy D. Rosenthal
Results Reporting
•
•
•
•
•
Web Text Results
Web Image Results
EMR integrated
Closing the loop
Critical Communication Management
Urgent Notification
Important Findings Alert
Continuously measure performance
Desk-top
Actionable
Report
Distribution
• Routine
• Urgent
• Critical
Protocol
Scheduling
•
•
•
•
•
Image appropriateness
Utilization
Decision Support
Exam Time and Location
Pre-procedure process
Reporting
• Data mining
• Ontology-Standard templates
• Decision support
•
•
•
•
Imaging Technology
Anatomic
Functional
Physiological
Procedure
• Customized service
• Patient preference
• Throughput
A value chain is a chain of activities that an industry performs to deliver a
valuable product or service (Michael Porter)
Radiology Value Chain
Desk-top
Actionable
Report
Distribution
• Routine
• Urgent
• Critical
Protocol
Scheduling
•
•
•
•
•
Image appropriateness
Utilization
Decision Support
Exam Time and Location
Pre-procedure process
•
•
•
•
Imaging Technology
Anatomic
Functional
Physiological
WASTE
Reporting
• Data mining
• Ontology-Standard templates
• Decision support
Procedure
• Customized service
• Patient preference
• Throughput
Radiology Value Chain
Desk-top
Actionable
Report
Distribution
• Routine
• Urgent
• Critical
Protocol
Scheduling
•
•
•
•
•
Image appropriateness
Utilization
Decision Support
Exam Time and Location
Pre-procedure process
•
•
•
•
Imaging Technology
Anatomic
Functional
Physiological
VALUE
Reporting
• Data mining
• Ontology-Standard templates
• Decision support
Procedure
• Customized service
• Patient preference
• Throughput
Radiology Value Chain
Desk-top
Actionable
Report
Distribution
• Routine
• Urgent
• Critical
Protocol
Scheduling
•
•
•
•
•
Image appropriateness
Utilization
Decision Support
Exam Time and Location
Pre-procedure process
•
•
•
•
Imaging Technology
Anatomic
Functional
Physiological
OUTCOMES
Reporting
• Data mining
• Ontology-Standard templates
• Decision support
Procedure
• Customized service
• Patient preference
• Throughput
Moving on…..
Change inevitable
Outcomes = incomes
Fee for service to Fee for value
Radiologists better positioned than many
because of digital nature of business
• Demonstrate (early) best practices to
hospital leadership
• Establish essential role within organization
•
•
•
•
The Imaging Value Chain
Delivering Appropriateness, Quality,
Safety, Efficiency and Patient
Satisfaction
THANK YOU