Radiology and EPR at the Brighton Radiology Visit

Radiology and EPR at the Brighton Radiology Visit • Anant Patel • Lead Radiographer (CG/RPS/IT/Redesign) • Mohmed Patel • PACS Manager Homerton University Hospital NHS Foundation Trust

Brighton Objectives • Visit EPR site with radiology integration (Anant) • Radiology Information System (RIS)/PACS & Desk Top Integration (Mohmed) • Applications integrated to RIS (Mohmed/Anant) • Q & As (Anant/Mohmed) • ? Anything else (Brighton contingent) Homerton University Hospital NHS Foundation Trust

EPR at HUH • Radiology paperless (Sept 2004) with 2 exceptions 1. Labels (contents)- act as request form 2. External referrals' (GPs/Mental Health) paper requests • Radiology film-less (PACS April 2007) • Desk Top Integration (2010) Homerton University Hospital NHS Foundation Trust

Contents • Radiology involvement with Homerton/Newham Programme • Future Flows • Issues • Other applications it’s integrated/interfaced with • The Good Homerton University Hospital NHS Foundation Trust

My Involvement with HUH EPR • • Involved with procurement (1999 -2003) Radiology System Designer for Homerton and Newham (2003 -2004) – – – Redesign Design decisions Additional hardware and software requirements • Training (2004) • Go Live then troubleshooting (2004 -2005) • Radiology EPR (2008 -) Homerton University Hospital NHS Foundation Trust

Why Cerner? • Cerner only one with a high level of integration (no maternity though) • Mc. Kesson (Bangkok) only had a few modules that were integrated (Pharmacy/Radiology) with RIS/PACS (Toulouse) • Siemens no real live system (Sweden), though RIS/PACS at Worcester • System C (Liverpool) too many interfaces and little confidence after demos • Cerner very good at selling from demos, to site visits (Detroit) to HQ environment (Kansas) • Cerner also able to demo majority of requirements on a live system even if we didn’t understand them fully Homerton University Hospital NHS Foundation Trust

Once Contract Signed. . • • • Current flows Design Consultancy Sessions Questionnaire Future Flows Making the design decisions Homerton University Hospital NHS Foundation Trust

Current Flows • Mapped paper flows – From requesting to results going to consultant in boxes • Needed stronger radiology voice regarding IRMER – Open requesting policy Homerton University Hospital NHS Foundation Trust

Design Consultancy Sessions • Sessions organised by Cerner to demo the solution to the system designers • Questionnaire provided to draw up future flows • This is your clinical contract with supplier! Homerton University Hospital NHS Foundation Trust

Questionnaire Contents • • Order processing (Powerchart etc) Order Entry Formats Patient Labels Cancel exams Radiographer info Radiology Report Additional Information Homerton University Hospital NHS Foundation Trust

Future Radiology Patient Flows – Four flows • Paper GP requests direct access (XR)- Department Order Entry • Paper GP requests schedulable (US)- PM Office • Direct EPR Referrals (XR, emergency CT, Mobiles etc)Powerchart/Firstnet • Schedulable requests (CT, MR, US etc)- Scheduling Homerton University Hospital NHS Foundation Trust

Homerton University Hospital NHS Foundation Trust

GP (Paper) Flow- A&C • Paper details copied to EPR Ordercomms – Not scanned, as could be easier for coding • Appointments added to electronic wait list – A&C initially schedule – Vetted/justified and rescheduled/cancelled/changed if necessary – Letter to patient • Direct Access entered onto Ordercomms • Exam to RIS worklist for that day Homerton University Hospital NHS Foundation Trust

OP/IP/A&E (Electronic) Flow • Requested electronically (referrers) • Appointments (A&C staff) – Queued then scheduled by A&C staff – Vetted/justified by IRMER pracitioners – OP Letter sent, otherwise IP/A&E verbally notified • Direct Access (non-schedulable) straight to RIS Worklist for the day Homerton University Hospital NHS Foundation Trust

Scheduling (Electronic) Flow • Check in (A&C) patient and ensure correct encounter selected – Notification when patients have checked in (status changes from Red to Yellow) • Check out (Radiographers) patients – Notification from Yellow to Red • Correspondence module associated to scheduling difficult to change for specific exams/modalities Homerton University Hospital NHS Foundation Trust

Radiographer Flows • • Check previous exams Start/complete/vet exam Add image usage/contrast/dose information etc Ensure data transferred to PACS Homerton University Hospital NHS Foundation Trust

Radiologist Flows • • • PACS centric flow Use templates or VR to dictate Sign immediately Homerton University Hospital NHS Foundation Trust

Future Hardware Flows • PCs at all areas where paper was used (viewing areas • Label printers for radiology and pathology (biopsy/drainage procedures) • Voice recognition/digital dictation hardware Homerton University Hospital NHS Foundation Trust

Other Applications linked with Radiology (RIS/PACS) • • • Powerchart (Nurse/Dr Application) Firstnet (A&E dept) Scheduling (OPD, Radiology, Theatres) PMOffice (PAS) Surginet (Theatres- not required) Casenote and Film Tracking (? ) Winpath (not Pathnet- Pathology) Keystone (electronic reports to GP via interface) BT/Sectra PACS (via Insignia PACS) Homerton University Hospital NHS Foundation Trust

PACS-EPR Homerton University Hospital NHS Foundation Trust

Order Entry Format Design I • • • Which fields needed? Which fields are mandatory in Powerchart (electronic requests)? Which fields are mandatory for paper requests Department Order Entry (DOE) ? Which fields are mandatory in PM Office (paper) and Scheduling (electronic)? See Synergy Article (Patel and Hogg 2009) Homerton University Hospital NHS Foundation Trust

Issues I- Technical • Support (in house very limited resources)– – – Non clinical New services – Mammos 4 years to develop Ca wait data hard to collect from CDS Updating slow- Mental Health/Podiatry referrers *Recommend similar model to BT helpdesk* • Not full integration between Radiology and Scheduling – Fields (consultants don’t carry over) – Cancelling scheduled appointments and then the exam • Servers overloaded Homerton University Hospital NHS Foundation Trust

Issues II- Clinical • IRMER– Workaround having schedulable to orders, i. e. vetting – Non Medical Referrers, Open Requesting Policy • • • Delays in lack of desk top integration (clinical risks) Encounters (patient episodes)- ZZ Section Clinical details (wrap around text) Obstetric US not integrated (separate system) More Radiology specific code sets (cancel reasons) Homerton University Hospital NHS Foundation Trust

Issues III- Multiple Sites • Standardisation of flows – Mostly the same – Workarounds when there are not • Newham patients coming across to Homerton – Requires IT admin communication between sites Homerton University Hospital NHS Foundation Trust

Issues IV- Targets • Ca not identified- still manual • Difficult to quickly look at waiting times, need an Information report • Information reports needed to be created by IT not RIS manager and dependent on a particular download • Current lack of awareness of DSCN 14/2009 and DSCN 18/2009 Homerton University Hospital NHS Foundation Trust

Issues V- PACS via Broker • Messages not always going across – Patient merges is intermittent – Minimum updates go across – Messages from DMWL do go across • Accession Linking reports not automatic • Clinical risks due to lack of DTI Homerton University Hospital NHS Foundation Trust

Issues VI- Misc • Communication – Need to test every change to the system even if not directly connected with radiology e. g. new isolation field code set – Paper work immense to get a change, more than BT PACS • Downtime/Contingencies – Full – Partial Homerton University Hospital NHS Foundation Trust

Additional Benefits • • Incidents- were auditable via Powerchart Incidents- picked up via PACS Privileges for referrers (non medical) Monitor work from any PC Homerton University Hospital NHS Foundation Trust

Good • • Couldn’t go back to old system Couldn’t go back to paper system Paperless except labels/consent forms Messaging goes across to PACS most of the time BT managing PACS, unfortunately not HUH EPR Request ‘forms’ can be vetted from anywhere Most actions auditable via information dept (from requesting, to rebooking) Homerton University Hospital NHS Foundation Trust

References • Patel, A. , and P. Hogg. 2009. Cutting the Paper Chain. Synergy , September 1, 26 -30. http: //www. proquest. com/ (accessed November 16, 2010) Homerton University Hospital NHS Foundation Trust