Bill Gregg; Mark Randolph; Denise Brown; Dinnia Smith; Tommy Lyles

A primary goal of all Radiology departments is to provide the proper diagnosis as quickly as possible. The time to make the exam available to the Radiologist for diagnosis can be broken down into two components. The first is performing the procedure and sending it to PACS. The second is a Radiographer reviewing the study on PACS and marking it verified. Once verified, it will appear on the Radiologist's worklist. Most current Radiology Information Systems can provide procedure time data, but they cannot provide data on when the exam arrived and was verified, unless the RIS and PACS are tightly integrated. Many institutions today have separate RIS and PACS systems and must look to the PACS to get this data. Traditionally, there has not been an easy way to measure the arrived-to-verified time. An in-house application for reading PACS audit logs was used to support the Process Improvement goal described here.

The department used for this study was General Radiology, which performed around 9,000 exams each month. The actual time taken to verify an exam after it arrived on PACS was gathered using the in-house PACS Auditor application over a period of 20 months from January 2007 through August 2008. The number of exams that took longer than 1 hour to verify were accumulated for each period as well, and the percentage of these exams was calculated. The materials used in this project involve software and hardware. The program development, database, and the program software used are:

Microsoft Visual Studio .Net 2005
PACS Auditor program (created in Visual Studio .Net)
Microsoft Office 2003/7 Access
PACS_Audit database

The project runs on a Dell Dimensions 9200 computer with a dual core 2.66 Ghz Intel Pentium processor with 2 Gb of RAM and a 320 Gb Raid 1 (mirrored) hard drive array.

The GE PACS version is Centricity 2.0 CSR1 SP5 software.

The data studied is provided by the PACS from the Event table. It includes Exam Changes such as ordered, arrived, verified, dictated, completed, canceled and reference only. These are separate event types, each with their own corresponding record(s) and data fields, which are extracted to an XML file. By looking at the event type and its date/time stamp, the time span can be determined between any of the steps in the workflow process. These include OA (ordered to arrived), AV (arrived to verified), VD (verified to dictated) and DC (dictated to completed).

The parameters measured in this study are:

AV (arrived to verified) time span

The XML file was created daily on the PACS, and exported to the Dell computer. An Imaging Informatics Professional collected and analyzed the data.

The following procedure was utilized for this study.

1. Gathering audit information created on the GE server.
2. Moving the XML log files to the computer used for storage of the audit information.
3. Executing the PACS Auditor load program to verify and import the data into Access.
4. Utilizing forms and reports to provide monthly time span reports.
5. Working with the Radiographer staff to review the report data.

The Radiology Administrator and Radiographer Supervisors identified a clear issue with getting exams verified in a timely fashion. The problem consistently appeared with Clinicians asking for a report on an exam that had not appeared in the Radiologists worklist yet. They incorporated this into their Process Improvement workflow and defined the goal as bringing the percentage of exams taking longer than 1 hour to verify to less than 10% of the total. There may be many factors that influence what would be considered an appropriate time, but some measure must be selected for comparison. The PACS Auditor was a tool created in 2004 to enable HIPAA-related audits and quick lookups regarding who verified or dictated an exam.[2] This first version looked at static events and displayed related data, and could list all the events for an exam, patient, or user. Any time span values had to be calculated by hand and could not be used effectively for the number of exams being reviewed here. In October of 2007 a set of Time Reports shown in Image 1 was added to the PACS Auditor which allowed the mining of the time span data such as arrived to verified.[1]

Reports could now be generated that would show aggregate times for all the spans, and could break the reports down by date range, modality, and shift. The reports also allowed the selection of a time limit for each of the spans, so any exams over the limit could be displayed and counted. By setting the time limit to 1 hour for the arrived-to-verified span, the number of exams over this limit could easily be retrieved. Image 2 shows a narrow selection of data that includes one > 1 hour AV span. The exam is displayed on a line above the aggregate data, starting with the accession number 3923. Below that the AV aggregate line shows an average of 27:05 minutes for a count of 3 spans, with 1 span being over limit (33.33%). In a typical month, there could be several exams over the limit, and limits could be set for any of the time spans. There would normally be counts and averages for all spans. Spans can be set for any integer hour value, and in the Total Time Ranges section each time span is broken out into counts per time segment (< 1 hr, < 2 hr etc.).

The Radiographer staff was informed of the PI goal and told that audits would be done monthly. Those reports were produced at the end of each month and provided the ability to drill down to the exam level. The data was then reviewed with the Radiographer staff driving the Process Improvement workflow and providing an impetus for change. Image 3 shows the counts and percentages by period starting with January of 2007 at the bottom and coming up to August of 2008. The total counts for all areas are shown in the first three columns. The next two simply show a breakout of our ER and 2nd Floor General Radiology sections. There are also three other sections not displayed.

Gregg B. “Maximizing the Power of Centricity PACS Audit Data.” Presentation at GE User Summit. August 20, 2008.

Gregg B, D’Agostino HD, Gonzalez Toledo, EC. “Creating an IHE ATNA Based Audit Repository.” Journal of Digital Imaging. 2006;Vol.19:4:307-315.