Integration saves time, spells win for patient care

One Saturday afternoon last month, Melissa, a star forward on the King's College women's field hockey team with a history of knee problems, presented to the Wilkes-Barre General Hospital outpatient clinic complaining of pain and instability in both knees. The hospital is part of the Wyoming Valley Health Care System.

This was her third doctor visit in four years with similar knee complaints. Melissa had been seen in 2002 and 2003, before WBGH implemented its integrated RIS/PACS. Both times, the examiner ordered x-rays to rule out torn ligaments or cartilage.

On the 2003 visit, as in 2002, she was examined by the on-duty physician. Melissa was given a sheet of paper with the exam order and told to take it to the radiology department. She hoped that the diagnosis would not be serious and she would be cleared to play in a National Collegiate Athletic Association qualifying tournament the following Tuesday. When Melissa arrived at radiology, she presented the slip at the registration desk. The radiology staff registered her into the HIS, which through an interface placed the exam order in the RIS.

A requisition order printed out, and Melissa soon was taken to in for the scan. At exam completion, she had to wait several minutes while the film was sent through the processor and verified. Radiology staff paperclipped the requisition slip to the processed film and placed both in a folder on a shelf in the file room. The film librarian then began a search for the prior 2002 exam. As in many file rooms before PACS, film location was tracked on index cards.

"With only a small onsite storage area, we were able to store a maximum of about six weeks worth of current film, after which film was stored in an outside storage facility eight miles away," said Nancy DeSando, PACS administrator.

To retrieve prior studies, requests went to a courier service, which would deliver film 12 times a day to the three different radiology reading rooms in the system.

Melissa's 2002 film folder could not be located.

"Prior to RIS/PACS integration, we had no immediate control over misplaced priors because it was a contracted service," DeSando said.

The radiology staff made a note of the missing priors on the current exam folder, then placed the study on a cart to await interpretation by a radiologist, who would eventually make a diagnosis without benefit of the prior study.

Melissa's physician did not receive the radiology report until Wednesday. Diagnosis: patellofemoral maltracking, no evidence of damaged cartilage or ligaments. Melissa was advised to ice the knee and wear a brace on it during athletic activity. She missed the Tuesday tournament. King's College lost.

Melissa's 2007 knee complaint was similar to the earlier episode, but in the meantime delivery of healthcare had improved at WBGH with implementation of an integrated RIS/PACS. Melissa still needed to present a slip to radiology registration, but everything after that had become streamlined, resulting in faster exam and report turnaround.

Now, when a patient presents to radiology, the RIS calls for all of the patient's prior exams to be available in the short-term cache on the PACS archive. No more paper requisitions. No more expensive couriers. No more missing priors. Technicians no longer have to wait for film processing to verify images. Melissa didn't have to wait around for possible retake.

When the exam is performed, technologists add comments via an interactive document that is displayed when radiologists launch the study on their work list. These comments can include contrast type and amount, clinical history, and call results phone number. Radiologists launch studies and priors using a single click within the RIS Read Exam area. The interactive document appears for the radiologist to review, all images load in PACS, and a dictation job within the digital dictation system is also launched.

In the event the patient presented through the emergency department or from hospital inpatient wards, images automatically follow the patient to the nearest PACS review workstation.

This time, Melissa's physician received the radiology report the same day. Diagnosis: patellar subluxation, without dislocation; pelvic stabilization exercises recommended, with continued bracing during activity. Melissa missed no games. King's College qualified for the NCAA Division III tournament.

"Report turnaround is now three hours for 90% of our studies," DeSando said.