IT integration puts patient care on faster track

A rugby incident sends 28-year-old Scott with a painful right knee to a medical clinic in Greenwich Village. The clinic is affiliated with nearby New York University Medical Center. A plain radiograph of the knee ordered onsite by his physician, Dr. Florence Workaday, shows no evidence of fracture. But to rule out torn ligaments, she refers Scott to the center's outpatient radiology clinic for an MR exam.

Affiliation in the digital era means more than hospital practice privileges. Workaday's clinic is integrated with new workflow engines at NYUMC.

"We have software that allows affiliated clinicians to log on to the hospital's electronic medical record through a Web-based application that gives them full access to patient orders, test results, imaging studies, and reports," said Chris Petillo, NYUMC's director of PACS.

Among other benefits, this allows Workaday to schedule the MR exam herself through a Web-based application developed by the radiology IT group at NYU that lets her schedule exams within certain open slots.

"It doesn't connect directly to the RIS at this point," Petillo said. "Someone has to take that information and actually schedule it in the RIS. But to the clinician, it is transparent and flexible."

One problem remains in NYUMC's quest for a completely integrated enterprise.

"Right now, the clinic probably uses a medical record scheme that is different from what is used at NYUMC," Petillo said. "The problem is how to link the two."

The solution NYUMC is implementing is a centralized registration system including an enterprise master patient index (EMPI) that provides one high-level enterprise-wide patient identifier no matter how many other conflicting medical record numbers the patient may have accumulated throughout the enterprise, according to Petillo.

Currently, hospitals have patients who enter the system at different points: hospital admittance, outpatient radiology clinic, dermatology clinic, or emergency department. This porous entry process generally results in multiple unique medical record numbers, which can become problematic for clinicians or radiologists attempting to retrieve a patient's complete medical record.

"The last thing I want is a situation where I'm reviewing a study and find out I don't have access to all relevant priors because the patient has different medical record numbers from previous visits," said Dr. Bernard Birnbaum, NYUMC's vice chair of radiology operations.

The EMPI scheme reconciles all the different patient numbering conventions inherent in the various EMR systems that become integrated with the hospital. By resolving contradictory medical record numbers, the EMPI plan gives the enterprise an advantage over its competition.

"The EMPI allows the hospital to reach beyond campus confines. Down the road, we see integration with the EMRs in private clinical practices enabling us to provide radiology and other services that departments in competing enterprises cannot," Birnbaum said.

In the NYUMC radiology department, the exams for Scott that have been requested from the clinician's office are monitored and immediately scheduled in the RIS. Workaday has flagged the case as acute, so the radiology secretary schedules the MR exam immediately. Patient data, which will arrive before the patient, are transmitted via document scanner from the clinic and inserted into the NYU radiology document scanning system.

If the patient happens to need a second study, such as an ultrasound, both appointments can be scheduled on the same screen. Here, the goal of integration is to schedule exams in such a way that the patient need not return between appointments, further streamlining healthcare for that person.

Once Scott's MR exam is complete, it appears immediately on various radiologists' work lists.

Currently, radiologists must spend time logging on to one computer system to retrieve patient information, another to retrieve PACS images, a third for the RIS, another to dictate reports, and still another for postprocessing of images. Efficiency suffers at every step.

When the NYU RIS implementation project is complete, true systems integration will instead provide a workstation that gives the radiologist single-click access, once the patient is selected on a work list, to all critical patient data: medical history, study indications, prescription information, handwritten notes, questionnaires, and exam-specific information provided by nursing or technology staff.

When the radiologist, Dr. Ray Ready, clicks Scott's name, the images are presented on the workstation, along with all ancillary information. With a single click, Ready has access to all pertinent information on that patient, including priors and medical history.

"Healthcare providers participating in the care cycle of the patient clearly benefit from having access to the full medical history, now available in the EMR," said Henri Primo, division manager for image management and PACS at Siemens Medical Solutions.

Time savings follow full integration.

"Access to all other medical documents in the EMR permits radiologists to address questions without having to conference with referring physicians, thereby saving time," said Dr. Elmar Kotter, vice chair of radiology at Albert-Ludwigs Universitat in Freiburg, Germany.

Efficient implementation of clinical pathways is impossible without system integration, according to Kotter.

"Clinical pathways must be supported by order entry and planning systems, which in turn must be tightly integrated with the EMR," he said.

After 2D analysis indicates Scott's ligaments are not torn, Ready wants 3D verification.

Systems integration will allow the radiologist to select these functions with ease, without changing stations or systems.

The 3D views confirm what Ready suspected: No sign indicates Scott's inner ligament is torn; only the outer ligaments are overstretched. Using the speech recognition system from the same integrated console, Ready dictates his findings. A text document is generated automatically and sent directly to Workaday. The entire study is sent to her, but key clinical images are flagged, reducing the time it takes for her to review the study.

The system sends an e-mail to the referring physician informing him or her of the availability of the radiology report, which can be reviewed on an office monitor, PDA, or laptop wherever the physician happens to be, Petillo said.

Three months later, Scott presents to the NYUMC emergency department after another rugby incident, with the same painful right knee. But this time, he also presents with an inability to bear weight. On examination of Scott's lower limbs by an emergency physician, Dr. Ozzy Coccyx, the right hip joint appears to be partially flexed, adducted, and internally rotated, with associated limb shortening. The right knee appears intact, with no evidence of distal neurovascular deficit. Coccyx suspects a dislocated hip and orders images from the radiology emergency diagnostic suite. A plain radiograph of the pelvis confirms posterior dislocation of the right hip with no associated fractures. Adequate analgesia is provided, and Scott is referred to orthopedics for further management. Surgery is scheduled as soon as possible. Scott gives up rugby.

"The ED has already registered Scott in the HIS, so when he is admitted to the hospital for surgery, he already has a hospital medical record number," Petillo said. "All they have to do is admit the patient and schedule the operating suite."

Immediately, the attending physician on the floor accesses a PACS monitor, pulls up Scott's EMR, and reviews his entire clinical history, including images and reports, then orders laboratory work and schedules other preop procedures, all from the same single-sign on system.

"The more integration that occurs, the more downstream systems are fed from the upstream system," Petillo said. "The demographics are cleaner, your points of integration are slicker, and your turnaround time is faster."

All of this integration translates into more convenient, faster patient care. Petillo gives an example from the NYUMC orthopedic department:

"Orthopedics, which has multiple offices within the medical center, will send a patient down to radiology for imaging and tell the patient to return to orthopedics after the examination," he said. "By the time the patient gets back up to the orthopedics office, the orthopedic specialist is already viewing the images and sometimes already has the radiology report. All this speeds up diagnosis."

Before the orthopedic surgeons arrive for the procedure, they order additional diagnostic imaging studies, including an MR examination. The reviewing radiologist now has access to Scott's complete medical history, including outpatient and inpatient comparison studies and all relevant priors, and he or she will be able to report within minutes.

Once a procedure begins, the operating suite has all the same medical information that the radiologist and the emergency physician had access to. The images are available electronically, and no one has to run around collecting film.

"Once electronic data are in one place, they are in all places, and everyone can share them," Petillo said.

Having all the data available online facilitates discussion between the radiologists and, in the hypothetical case, the orthopedic surgeons, according to Primo. Radiologist and surgeon can share a complete view of the patient record and can discuss diagnosis and treatment options.

"Having access to the complete medical record of the patient is of utmost importance for the team of caregivers, including referring clinicians, radiologists, emergency physicians, orthopedic surgeons, nurses, and technologists," Primo said.

Integrating systems enables the entire enterprise to develop a uniform, internally consistent healthcare environment, which translates into economic efficiency and better patient care.