Understanding Image Quality in a Digital Environment
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| Authors: |
Mary-Theresa Shore, MSM, Massachusetts General Hospital; Kathy Tabor-McEwan |
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| Hypothesis: |
Creating a consistent process by which radiologic technologists enter data at the imaging modality, perform the imaging study, and then perform a quality check prior to sending to PACS, improves image quality, and decreases errors and rework, which benefits patient care.
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| Introduction: |
In many radiology departments across the country, technology has changed the method by which radiologists and clinicians view radiological exams, reports, and other patient information. Picture Archiving and Communication Systems (PACS) have been implemented to replace the legacy film-based departments and transition them into digital imaging departments. Long gone are the view boxes (light boxes) where radiologists wpi;d hang xrays to view images. Instead, images are transmitted across networks to computer terminals where radiologists and clinicians can view images, reports, and any other medical information available on that patient.
When a PACS is configured to meet the clinical and operational requirements of a healthcare institution and integrated with a radiology information system (RIS), a PACS has a direct impact on costs, efficiencies, and productivity.
Examples include:
-Reduction of film, film handling, and chemical costs
-Reduction of storage space requirements
-Improved access to images and patient data over a wide area
-Integration of images with the radiology report and other patient information
-Increased productivity (15% to 20%) for radiologists and technologists
-Increased efficiency (15% to 20%) for radiologists and technologists
-Improved communications between clinicians and referring physicians
-Ability to provide medical images as part of the electronic medical record
Anytime a new system is implemented, the easiest part of the installation is the equipment. The most difficult part is change management. Change usually involves the introduction of new procedures, people, or ways of working, which have a direct impact on the various stakeholders within an organization. The key to successful change management lies in understanding the potential effects of a change initiative on these stakeholders. Just about everyone that works in radiology, or who needs to access radiology images, were affected by this change. However, the group that was most affected by this transition was the technologists. It is with them that the process of image acquisition and delivery begins and ends.
Transforming a radiology department from a film-based system to a digital imaging system is no small undertaking. It’s impressive, especially at a large institution like Massachusetts General Hospital, where over 700,000 radiological exams are performed annually, that the implementation went as well as it did. However, it was not perfect, and trends began to develop that were impacting the department negatively, both clinically and financially. Those trends included an increase in the number of errors in image and data integrity. Based on data collected by the PACS team, a workflow analysis was created and carried out in the emergency radiology department at Massachusetts General Hospital to identify the reasons why there was an increase in the number of overall errors and, more importantly, how to reduce or completely eliminate those errors. |
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| Methods: |
| A workflow analysis was conducted in emergency radiology and outpatient radiology with radiologic technologists performing MRI, CT, Ultrasound, and General Radiography with attention on workflow that included transmitting images to PACS. Secondary data collection methods were used that included an online database to track both image integrity and data integrity errors. This database, although primarily created for documentation purposes, was found to be invaluable for identifying trends such as error per shift, errors per technologist, and errors per modality, as well as the overall total number of errors during this workflow analysis. Additionally, using this analysis we were able to categorize issues into Image Integrity and Data Integrity. There were six error classifications in the category of imaging integrity (positioning, technique, protocols, demographics, proper labeling, and completion report) and six error classifications in the category of data integrity (cancelled exam, mis-labeled, merged, mis-identified, mis-scheduled and unverified). Three months of data was collected and categorized prior to the implementation of process workflow changes, and three months of data was collected and categorized post implementation. |
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| Results: |
A total of 33,761 imaging studies were performed over a six-month period in Emergency Radiology. Prior to implementing consistent workflow, 140 imaging errors occurred spread over six classifications, 175 data integrity errors occurred spread over six classifications, resulting in a total of 315 errors. Post implementation of a consistent workflow process, errors decreased to 40 imaging errors and 42 data integrity errors, for a total of 82 errors. Man hours spent fixing errors (i.e., broken studies) decreased by 50%, from 89 man hours to 43 man hours. This decrease in errors reduced the time needed to fix errors by Managers, Technologists and PACS analysts’. |
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| Conclusion: |
Creating a consistent process drive workflow, by which technologists enter data at the imaging modality, perform the imaging study, and then quality check the image and data prior to transmitting to PACS, will improve image quality, will decrease data integrity errors, and will improve the quality of service to patients, as well as decrease the financial impact related to correcting mistakes. The overall goal of this project was to promote operational efficiency and provide the highest quality care for patients.
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