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Running head: FINAL PROJECT

Final Project
Bernard Godfrey
Siena Heights University
Dr. Schoenbart

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Final Project

Radiology departments are highly technical areas that, like many other departments, have
endured changes over the years when it comes to Information systems. Information systems
touch nearly every aspect of delivering the service of radiology. Radiology was once a
department full of light boxes and dark rooms. Now they are highly advanced areas with control
rooms and reading stations. The technology is always changing. Information systems have
affected workflow of the department access to imagesand quality of care. The delivery of
radiology is quite different than it used to be.
Workflow is a concern for many areas of an acute care hospital; radiology is no
exception. Because of the rise in healthcare expenditures over the last few decades, work flow
has become a major concern in order to decrease some of the costs of healthcare delivery. Also,
patient safety is a concern. According to Glandon, Smaltz, and Slovenski (2013) attention was
increased after the publication of to Err Is Human in 1999 by the Institute of Medicine. Because
of the large amounts death due to medical error, many groups including the legislative and
executive branches of the government became involved. The Institute of Medicines report
advocated for higher use of health information technology (HIT) in order to prevent errors.
In 2009 the federal government passed the Health Information Technology for Economic
and Clinical Health Act (HITECH). Its goal was to promote the development of a nationwide
HIT infrastructure, provide leadership in the development of standards, provide the certification
for HIT products, coordinate HIT policy, perform strategic planning for HIT adoption, and
establish the governance for the Nationwide Health Information Network (Sultz, & Young,
2014, p. 78). Similarly, HIT could save costs. . A study by the Rand Corporation published in

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Health Affairs suggested that $81 billion in aggregate could be saved annually as a result of EHR
adoption (Glandon, et al., 2013, p. 275).
Included in the HITECH act is a Medicare and Medicaid incentive program called
Meaningful Use. The meaningful use program includes incentives given to physicians for
implementing an electronic health record (EHR). Some of the core objectives are: use computer
physician order entry (CPOE) for orders entered by the provider doing the ordering,
implementation of drug and allergy cross referencing, maintain a problem list of active diagnosis,
the transmission of prescriptions electronically, medication lists for patients, allergy lists,
recording demographics of patients, record changes in vital signs including (height, weight,
blood pressure, etc.), reporting of quality measures to CMS, the implementation of CDS and the
tracking of it, provide patients with their health record when it is requested, provide clinical
summaries for each patient visit, the exchanging of information between providers, to protect
health information (Glandon, et al., 2013). One can see how the objectives of the meaningful use
program could affect radiology. First, the adoption of CPOE has had an effect.
Computerized Physician Order Entry (CPOE) is a component of the EHR system that
allows physicians or providers to directly enter an order into the system. Prior to CPOE
physicians or providers would write orders on a physicians order sheet in the chart. The nurse or
unit secretary would put the order into the computer in order for it to go to the respected area.
The problem wasthere was a lot of room for error. Orders didnt get put in, they were lost, or
worse yetthey were put in wrong. CPOE allows the physician to put an order in real time. It
also allows them to know the correct order is placed. Furthermore, it has Clinical Decision
Support (CDS) which helps the physicians avoid errors in ordering the wrong test or
inappropriate test.

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Another HIT technology that had an effect on workflow in radiology was the Picture
Archiving and Communication System (PACS). This had a profound effect. Before PACS,
radiologic technologist and radiologists relied on film to view images. It was costly to operate
dark rooms because of chemical costs, QA testing, and film expenses. The chemicals were
hazardous and the darkroom required constant upkeep. Similarly, the films and film jackets had
to be stored in a physical space on-site. Also, the radiologists required large viewing stations that
took up space. The Picture Archiving and Communications System (PACS) refers to a computer
system that is used to capture, store, distribute and then display medical images. Electronic
images and reports are transmitted digitally via PACS. This eliminates the need to manually file,
retrieve or transport film jackets (Kalispell, nd. Para. 1). Radiology suddenly had more space.
The need for film libraries went away. Not only did they get more spacethe productivity went
up.
The availability of the Picture Archiving and Communication System (PACS) has
revolutionized the practice of radiology in the past two decades and has shown to eventually
increase productivity in radiology and medicine (Mansoori, Erhard, & Sunshine, 2012, p. 229).
PACS made imaging digitized. Radiology departments now had the ability to send images and
receive images digitally. This made the time from imaging to reading much quicker. For instance,
prior to PACS a CT technologist would perform a CT and send the images to a film processor.
The processor would develop the films. Staff would then hang the images on a viewer for the
radiologist to read. This could take quite a bit of time. Now, with PACS, the images are sent
directly from the CT scanner to the radiologists viewing station in a matter of seconds. Work
flow and productivity has dramatically gotten better.

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Not only was digital radiography (DR) more efficient, the image quality was also affected
by the digitizing of radiology exams. The efficiencies of DR are well documented. It is a truly
digital system with no cassettes and therefore none of the time consuming steps needed to
process them. Images are ready for viewing in seconds instead of minutes, and DR produces
excellent spatial resolution and higher quality images (IDC, 2006, para. 14). Because the spatial
resolution is higher, it is possible to use less radiation. Also, accessing the images is easier.
When hospitals adopt an EHR system, they have the ability to allow caregivers across the
organization to electronically access those images. Contemporary EHRs provide a means to
make PACS images available to caregivers outside of the radiology department (Glandon, et al.,
2014, p. 262). This was the first time that caregivers could view images from anywhere including
the ED. Franczak, Raslau, Bergholte, Mark, and Ulmer (2014) concluded that access to
the EHR is necessary to radiologic decision making in the ED setting. Health care providers must
recognize the value of implementing EHRs and the potential harm that may come from their
absence, while policy makers need to continue to work toward nationwide exchange of health
information (p. 800).
Since the onset of digital imaging, rural areas and small health organizations now have
access to quality readings by certified radiologists as well. This is through the development of
teleradiology. Teleradiology is a way for organizations to send images to a radiologist to read off
site. Teleradiology is used by many different types of practices such as hospitals, urgent cares,
private practices, mobile x-ray companies, and imaging centers. Teleradiology improves patient
care by allowing radiologists to provide services without actually having to be at the location of
the patient. This is particularly important when a sub-specialist such as a MRI radiologist,
neuroradiologist, pediatric radiologist, or musculoskeletal radiologist is needed, since these

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professionals are generally only located in large metropolitan areas working during day time
hours. Teleradiology allows for trained specialists to be available 24/7 (Rapid, nd., para 2).
Not only is it possible to send images to teleradiology services, it is also possible to send
images to other facilities for continuance of care. According to Glandon, et al. (2014) the
Certification Commission for Healthcare Technology (CCHIT) is currently developing
certification standards to enable reliable exchange of information across multiple entities (p.
152). This is a step in the right direction. The US Department for Health and Human Services
Office of the National Coordinator for Health Information Technology (ONCHIT) think that
health information exchange is needed to lower the overall cost of healthcare and to provide
good care to the patients. Healthcare organizations need to link to outside institutions or
providers for both business and regulatory reasons (Glandon, et al., 2013, p. 152). Soon it will
be possible to send a patients prior images to any hospital they are being treated in. It is an
exciting time.
The Patient Protection and Affordable Care Act (PPACA) supports a national strategy of
quality improvement that emphasizes the integration of services for hospitals, providers, freestanding clinics, or other independent providers. This is done through shared electronic records,
guidelines set for clinical purposes, and collective practices. In optimal systems-based care,
each patient's health care needs are evaluated and treated comprehensively as part of a "system"
of care for that person (Belmont, Haltom, Hastings, Homchick, Morris, Taitsman, and Peisert,
2011, p. 1283). All public hospitals are now connected via the image exchange portal (IEP) set
up by the government, running over N3 (the new NHS network), for direct electronic inter-site
transfer of imaging studies and their reports, thereby removing security risks and technological

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incompatibilities (Stricklen, 2015, p. 115). It is likely that private hospitals will soon follow
suit.
The adoption of PACS and EHR have had an effect on efficiency leading to higher
quality; however, no other system has had an effect on efficiency and quality in the radiology
department quite like the Radiology Information System. The radiology information system
(RIS) is considered the core system for the electronic management of imaging departments.
Within a radiology department, major functions of the RIS can include patient scheduling,
resource management, examination performance tracking, examination interpretation, results
distribution, and procedure billing (McEnery, 2013, p. 1). It is the key component to a modern
radiology department.
RIS is a sophisticated electronic booking and workflow tracking system, whereby
imaging examinations are scheduled and tracked through their various stages of completion. RIS
records when: the patient has arrived for the examination; the examination has been
performed/completed; and the report has been dictated and verified (signed off) (Stricklen,
2015, p. 115). Before RIS scheduling, a scheduler would use a paper schedule to keep track of
appointments in radiology. As departments grewmodalities expandedand tests became more
complex, the need for computerized scheduling was apparent. RIS scheduling function can
simultaneously schedule any modality with multiple levels of complexity. Also, it gives all
radiology staff the ability to schedule patients from anywhere at any time throughout the
workday.
Along with scheduling, RIS is capable of billing the radiology procedures that are
performed. This includes necessary CPT codes and ICD-10 codes. Along with the billing of the
exam, the RIS has the capability of adding on additional charges such as exam related charges. In

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radiology this can range from the amount of contrast given to 3D rendering. RIS systems process
electronic payments and automated claims. They can also have the ability to keep detailed
financial records. The RIS billing capability has improved radiology billing exponentially. The
less billing errors that occur means third-party payers are less likely to delay or deny payment for
claims.
RIS systems can also track patients records in radiology. Using a RIS system, providers
can track a patient's entire radiology history from admission to discharge and coordinate the
history with past, present and future appointments (HealthIT, nd. Para. 3). RIS can also track
statistical data that a manager may want to know such as examination performance tracking and
utilization data. Furthermore, the RIS system is the key component for results distribution. Prior
to the adoption of radiology information systems, the reading for the imaging study would be
mailed to the ordering provider. This could take days. Now, with RIS capability, the radiology
department can electronically send the results in seconds. Raising the quality of the service and
more efficient patient care.
Some studies have shown that having access to PACS and RIS can reduce the length of
stay for inpatients. When studying whether access to diagnostic imaging results reduced hospital
length of stay Hurlen, Ostbye, Borthne, & Gulbrandsen, (2010) concluded that even with
improved clinical access to the results of diagnostic imaging, we could not identify a
corresponding reduction in the length of hospital stay when all patients were considered together.
However, one subgroup of patients, namely those with CT scans, had 25% shorter hospital stays
after the introduction of RIS and PACS, and the integration of these systems with the EMR.
Given the clinicians particular interest in CT reports it is likely that this reduction in length of

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hospital stay in part was caused by the improved clinical access to these reports (p. 5). It was a
promising result.
The future of information technology in radiology doesnt seem show signs of slowing
down. The 113th congress proposed section 218 (B) which required all physicians ordering high
end imaging will have to process it through clinical decision software. This was proposed to start
January 1, 2017. It was a way to attempt to reduce costs caused by over-utilization and to use
evidence based medicine when ordering radiology exams. However, the Centers for Medicare
and Medicaid Services (CMS) has postponed its January 1, 2017 deadline for physicians to use
clinical decision support (CDS) software, based on appropriate-use criteria (AUC), when
ordering diagnostic imaging tests (Hagland, 2015, para. 1). This is a sign that the we will likely
see this happen in the future.
According to Miliard (2015) a study that polled 554 imaging professionals that asked
what they see as the most exciting new imaging IT technology showed:

Cloud-based image sharing (26 percent)

Vender Neutral Archive (VNA) (23 percent)

Advances in dose management (16 percent)

Clincal decision support (11 percent)

Universal viewers (9 percent)

Analytics (7 percent)

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CAS (5 percent)(para. 5).

I have to admit; these new trends look exciting. The future of cloud based storage and VNA
looks incredible. Also, clinical decision support. From the time I first learned about it, I have
thought it would be beneficial. It puts evidence based medicine at the fingertips of all providers
ordering imaging studies. During the early 2000s medical imaging costs were rising at a faster
rate most other medical service areas. That quick rate of growth resulted in reductions in
payments from Medicare payments for medical imaging services. According to the Neiman
Report of the American College of Radiology (2012) at the same time that Medicare payments
were decreasing the use of radiology benefits managers (RBMs) by private payers grew
dramatically while real-time order entry clinical decision support (CDS) was introduced and
implemented in prestigious medical centers. CDS is now commercially available and is being
increasingly incorporated into hospital and health system information platforms (p. 1).
Furthermore, the use of analytics is becoming more and more prevalent in running a
radiology department. GE, Siemens, and possibly other vendors now offer analytics created at
the source. For instance, as a radiology manager I may want to know how long there is idle time
on the MRI machine. The analytics data can determine how long it is between patients, between
exams, and even between sequences. It helps managers fix process problems. This data is pulled
directly from the machinery and not an RIS or PACS system. It is data we didnt think of
collecting in the past.
Since I started in the radiology field about 25 years ago, I have witnessed tremendous
changes. It seems like yesterday we were developing films in the dark room. It has been amazing
to witness. We now send advanced imaging over the internet to be read by a radiologist sitting in

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a chair that is sometimes halfway around the world. I am still amazed. Similarly, it has been a
pleasure to be a part of the radiation reduction era. We now send data to the National Radiology
Data Registry (NRDR). The NRDR is working to establish benchmarks on the amount of
radiation that is appropriate per exam. It is a daunting task. I am proud to say I have been a part
of it. Information systems have an effect on all aspects of radiology. From the scheduling of an
appointment to the storage of images; it is the core of what we do and how we do it. It continues
to evolve at a rate that is hard to keep up with. It has been a pleasure to see the changes and I am
excited about the future.

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References
Belmont, E., Haltom, C. C., Hastings, D. A., Homchick, R. G., Morris, L., Taitsman, J., . . .
Peisert, K. C. (2011). A new quality compass: Hospital boards' increased role under the
affordable care act. Health Affairs, 30(7), 1282-9. Retrieved from
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Franczak, M. J., Klein, M., Raslau, F., Bergholte, J., Mark, L. P., & Ulmer, J. L. (2014). In
emergency departments, radiologists' access to EHRs may influence interpretations and
medical management. Health Affairs, 33(5), 800-6. Retrieved from
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Glandon, G. L., Slovensky, D. J., & Smaltz, D. H. (2014). Information Systems for Healthcare
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CTmGvYvLTh

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(PACS) implementation, integration & benefits in an integrated health system. Retrieved
August 8, 2016, from http://www.ncbi.nlm.nih.gov/pubmed/22212425
McEnery, K. (2013). Radiology Information Systems and Electronic Medical Records. Retrieved
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Miliard, M. (2015). New trends ahead for imaging informatics. Retrieved from
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Neiman Report. (2012). Retrieved August 10, 2016, from
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Strickland, N. H. (2015). Imaging informatics: The role in radiology. British Journal Of
Healthcare Management, 21(3), 115-116

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