New Radiology System Designed to Reduce Wait Times

Faster, Better Healthcare for Patients Makes Life Easier for Staff Too

Wednesday, January 03, 2007

CINCINNATI – Patients in need of X-rays, CTs (computed tomography), MRIs (magnetic resonance imaging) and other imaging services from radiology, will be triaged more quickly and efficiently under a new system conceived by and in use at Cincinnati Children's Hospital Medical Center.

The system, called RadStream, is the first of its kind. It was developed by the Radiology Informatics Research Core at Cincinnati Children's in collaboration with researchers from the University of Cincinnati College of Business. To measure its impact, the team's conducting a concurrent, longitudinal research study focused on operational and organizational metrics as well as patient and hospital staff satisfaction.

Initially, RadStream was developed at Cincinnati Children's as an effort to triage emergency department patients more efficiently. It has since grown into a hospital-wide effort to deliver radiology services more quickly, support department-wide paperless workflow, accurately and automatically triage radiology exams, enhance communication within and beyond radiology, and provide permanent documentation of communications regarding important radiology findings with referring physicians and other health care providers.

"We built RadStream to improve our existing state of the art filmless radiology system, which uses voice recognition technology to provide electronic radiology reports. The fundamental improvements we made to our workflow could be used to improve the delivery of health care in any clinical arena, anywhere in the world," according to Mark Halsted, MD, associate professor of radiology and chief of the Radiology Informatics Research Core at Cincinnati Children's.

The new system also creates a more seamless workflow for exams coming from all parts of the medical center, including ten satellite locations, where communication and coordination often become challenging among so many staff, residents and fellows.

Prior to RadStream, radiology workflow was similar to that of other institutions. Incoming imaging requisitions arrived by fax and often patients were treated on a first come, first served basis. There was no good overview of departmental operations, so a technologist at an outpatient satellite where business was slow might call the main hospital to expedite reading of a concerning case, without realizing that the radiologist was already swamped because of high traffic from clinics, the emergency department, or other sites. Well-intentioned phone calls from technologists and ordering physicians caused frequent interruptions to radiologists' workflow at the busiest times -- precisely when the radiologists needed to work at their peak efficiency.

Radiologists often cite interruptions as a factor leading to work stress, reduced job satisfaction, and even errors. RadStream led to a 22 percent reduction in interruptions among radiologists at Cincinnati Children's, which adds up to approximately 12 minutes per shift or, for the department as a whole, one full-time radiologist per year.

The research team also addressed other communication issues. "We improved the communication and documentation of critical results to our referring physicians without increasing the burden of these tasks on our radiologists. At the same time, we wanted to improve communication amongst ourselves so that it was clear to everyone which technologist and which radiologists were involved in any particular case at any given time, regardless of their physical work locations, the source of the images, or the time the images were acquired. It is frustrating, inefficient, and leads to confusion that can degrade patient care, to begin dictating a case only to discover that your colleague has already begun working on it," Dr. Halsted said.

With RadStream, overall process flow times were significantly reduced for radiology patients at Cincinnati Children's. Decreased flow times were observed in every step of the process. On average, 61 minutes was saved in exam reading times across all patient classes studied. Improvements were most notable in patients visiting satellite locations and the emergency department (ED). ED exams were read 21 minutes quicker on average, with nearly 80% read in under an hour. RadStream cut nearly 90 minutes from satellite exam reading times, and roughly two-thirds of all satellite exams are now read within an hour.

Due to the widespread efficiency gains brought by RadStream, all studies are now read faster, regardless of whether they are routine or urgent. Added Dr. Halsted, "We also built communication elements to decrease workflow interruptions. RadStream combines these tools so that, rather than simply speeding interpretation of the most urgent cases at the expense of routine ones, it improves all aspects of our workflow – now, even routine studies are reported more quickly."

Radiology is central to diagnostic and treatment decisions, and the sickest patients require the most rapid diagnoses and treatments. But before RadStream, another headache for radiologists was to determine what STAT meant, because the term has become overused in health care. STAT exams could mean anything from "patient seen in clinic for chronic abdominal pain – need results this afternoon" to "patient life-flighted to the emergency department with major trauma -- need results immediately." Now, RadStream automatically prioritizes more seriously injured patients.

"It only made sense that we should make every effort to interpret the sickest patients' studies first, without having to sort through stacks of requisitions marked STAT, which were often 30 exams or more deep," said Dr. Halsted. "Patients with acute fractures, in significant pain and needing urgent treatment were sometimes waiting longer for radiology interpretations than comfortable patients with chronic issues who happened to arrive in the department first. We felt that we could do a better job guiding our radiology staff as they deliver acute radiology care, by getting away from stacks of paper requisitions and providing them with a dynamically sorted electronic reading list, based on the acuity of all cases waiting for interpretation."

Employing a unique algorithm created specifically for the system by experts from UC's College of Business, RadStream automatically prioritizes cases based on the patient's medical severity, psychological state, and various operational factors, like patient waiting times and departmental goals for turnaround times, that can affect the delivery of care. This automation frees up medical resources and helps ensure that patients are prioritized in a timely and consistent manner.

"We knew that we could benefit from a collaboration with colleagues from UC's College of Business. These are the people who, for instance, consult with shipping companies to make sure that their trucks run the most efficient routes and remain full as often as possible. We realized that they could help us improve our work flow and help us measure whether changes we implemented actually had a desired effect," said Dr. Halsted.

"The algorithm's performance showed high agreement with actual triage decisions made by experienced radiologists, which was a challenge given the inherent subjectivity of the task," said Craig Froehle, Ph.D., the lead UC College of Business team member and assistant professor in Quantitative Analysis and Operations Management.

Further results will become available as the measurement component of the research is completed. In addition, Cincinnati Children's continues to search for a major technology-based healthcare company to license the software and offer it for use in other hospitals nationwide.

About Cincinnati Children's Hospital Medical Center

Cincinnati Children's, one of the top five children's hospitals in the nation according to Child magazine, is a 475-bed institution devoted to bringing the world the joy of healthier kids. Cincinnati Children's is dedicated to providing care that is timely, efficient, effective, family-centered, equitable and safe. For its efforts to transform the way health care is provided, Cincinnati Children's received the 2006 American Hospital Association-McKesson Quest for Quality Prize". Cincinnati Children's ranks second nationally among all pediatric centers in research grants from the National Institutes of Health and is a teaching affiliate of the University of Cincinnati College of Medicine. The Cincinnati Children's vision is to be the leader in improving child health.

About the Division of Radiology at Cincinnati Children's

Radiology at Cincinnati Children's is recognized as a leader in process improvement, research, education and clinical care in pediatric radiology. As one of the busiest pediatric radiology departments in the country, the department currently employs over 200 full-time staff, 30 clinical faculty, and 8 PhD researchers, and performs over 180,000 exams per year. Radiologists staff the 423 bed teaching facility and 16 regional outpatient centers. The department also trains approximately one-third of the graduating pediatric radiology fellows nationally each year. In fact, this year the division is in its 56th year of training pediatric radiology fellows -- one of the oldest radiology fellowship programs. Among the top well-funded pediatric imaging research facilities in the country, it is a forerunner in areas such as functional neurology MRI, dose reduction in pediatric CT, frequency of sedation reduction initiatives, imaging in obesity, and imaging in obstructive sleep apnea. For more information about radiology at Cincinnati Children's, got to www.cincinnatichildrens.org/radiology.

About the Radiology Informatics Core at Cincinnati Children's

The Radiology Informatics Care is a team of experts based in the division of Radiology at Cincinnati Children's. Much of their work is on the cutting-edge with processes for automatic radiology triage, paperless workflow, efficient communications, electronic teaching files, and error reduction by utilization of a difficult case curriculum for teaching residents and fellows based on errors commonly made.

About University of Cincinnati, College of Business

The University of Cincinnati's College of Business is a leader in experienced-based education and high-impact research. Integrating real-world experiences from co-ops and field studies with world-class faculty expertise provided in the classroom helps students develop the skills, intuition and confidence that contemporary business demands. Timely research and hands-on learning build knowledge of specialized business professions and interwoven themes of internationalization, technology and venture creation.

UC's College of Business celebrates its centennial year in 2006. The Cincinnati College of Finance, Commerce and Accounts was established as a private college in 1906. In 1912, the University of Cincinnati Board of Trustees took over the college and established the College of Commerce as an integral part of the university. In 1919, the College of Commerce was merged with the College of Engineering to form the College of Engineering and Commerce. In 1946, the college resumed operation as a separate entity, the College of Business Administration, and offered its own baccalaureate. In 1958, a Master of Business Administration (MBA) program was started; in 1966 the PhD program was added; and, in 1978, a Master of Science (MS) program was begun, which is now offered in six disciplines. The "College of Business Administration" dropped "administration" from its name in 2003 to become what it is today: UC's College of Business.

Co-operative education, the hallmark of the University of Cincinnati, is available in most programs and is optional in all. Undergraduate enrollment at the college is more than 2,000 students, with a male-to-female ratio of approximately 1.6:1 and a student to faculty ratio of 24:1. Approximately 90 faculty members are composed of full-time to part-time instructors at a ratio of about 5:1.