ORDER ENTRY IN RADIOLOGY

ORDER ENTRY IN RADIOLOGY

DANIEL I. ROSENTHAL

Electronic order entry for diagnostic imaging offers many potential advan- tages for both the radiology department and its referring community.

Despite this, it is not a widely available service, especially for outpatient prac- tices. This lack of penetration may be due to the cost and complexity of initial deployment. However, it may also represent failure to comprehend the full range of possible benefits or to understand the barriers to acceptance by cli- nicians and radiology personnel.

Implementation of an electronic system is a major investment in time and effort. It is also an exercise in change management in regards to both the referring practices and the radiology department. Electronic order entry may be perceived either as positive or negative depending on whether the users acknowledge the problems that the system is designed to address. For example, it is very difficult to persuade referring offices to comply with a system whose primary benefit is to enhance radiology billing. For this reason, in our large (more than 100 radiologists, 5 locations) academic medical center, we believe that it is very important that the order-entry system be designed with the needs of both user groups in mind. Only then will the initial effort of learning a new procedure appear worthwhile.

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C H A P T E R

At present, there are no widely accepted, radiology-specific electronic order-entry systems on the market. We have created our own electronic order-entry system that functions very well. It is described here to demon- strate what can be accomplished when such as system is tailored for radiol- ogy instead of being just a part of a generic order-entry system. Our system was designed empirically and has undergone constant growth and modifica- tion as new capabilities were recognized. It is hoped that systems such as this will soon be commercially available.

P R I N C I P L E S

Our outpatient Web-based order-entry system was designed with several basic principles in mind:

1. The minimum essential information needed to perform the exami- nation must be captured through the use of mandatory fields. This includes patient, doctor, and examination identification, as well as enough clinical information to assign at least one ICD-9 code (required for billing).

2. All information is electronically transferred to the radiology infor- mation system (RIS).

3. Total time for use of the system must not exceed that for a manual system. Keystrokes are kept to a minimum. Since use of the system requires access to a computer, it may be perceived as less convenient than a paper system for ordering, especially for inexperienced users. However, improved scheduling more than compensates for this. Therefore, we have found it important for initial user acceptance to focus on those examinations that require advance appointments (most procedures other than plain radiography).

4. Not every examination can be included. We do not think that electronic order entry is appropriate for urgent or “stat” cases because of the risk that they may not be noted rapidly enough. Interventional proce- dures require more detailed communication than the system is designed to handle.

5. Some adjustments by “expert users” will continue to be required. It appears unreasonable to burden the users with the full range of possible pro- cedure codes. The final assignment is done within the radiology department either by schedulers or by technologists.

D E S I G N

In the mind of the user, the process of ordering a diagnostic imaging test probably includes the process of scheduling. Different individuals may be responsible for these 2 components. The physician or nurse may write an order in a patient record. The task of scheduling the appointment is often left for a secretarial assistant. We think that it is important that the elec- tronic system provide for both functions, as the greatest advantages for the referring practices are in scheduling convenience.

Our system requires a password-protected log-on for all users, includ- ing both physicians and office assistants. At the time of initial registration, each user must indicate for whom he or she is authorized to order exams.

Physicians generally order only for themselves. Office staff may sometimes order examinations for a few physicians. This information is stored in the order-entry database and can be edited if required. For each subsequent use, the user sees only the authorized names on a pull-down menu.

Patient identification is done by means of the medical record number.

The system verifies the validity of the number and returns the patient name for additional verification.

After identification of the doctor and the patient, the main ordering screen appears (Figure 24.1). This is a listing of modalities (computed tomography [CT], magnetic resonance imaging [MRI], etc.). A click on the modality icon reveals a pull-down menu of examinations (chest, abdomen, head, etc.). When the proper examination is selected, the specific ordering screen appears.

All ordering screens have the same basic structure, intended to mirror clinical practice. A checklist of indications is offered, permitting selection from 3 different categories (Figure 24.2):

1. A sign or symptom 2. A known diagnosis

3. An abnormal previous test

Selection of at least 1 of these boxes is mandatory for scheduling to proceed.

Multiple selections may be made, and a free-text box (optional) is provided for additional information. In addition, a listing of common special consid- erations is offered. These are intended to minimize the need for free text and include common requests such as the use of contrast, conditions to rule out, requests for “wet readings,” or additional physicians to be sent reports.

Selection of 1 or more of the special considerations is optional.

The lists of common indications and special considerations for each examination were developed using a multistep process. Billing submissions from the years prior to order entry were reviewed to identify commonly used terms. These lists were validated against published listings of medical appro- priateness. The lists were then verified by subspecialist radiologists. Finally, prior to creation of the electronic system, the lists of indications were piloted in paper form. Indications were added as needed and removed if not used.

Modification of these lists is ongoing.

Once the necessary information has been provided, the user has the option to save the order or proceed to schedule an appointment. Physicians may prefer to have their office staff do the latter.

Clicking on the Schedule icon brings up a screen showing a list of sites at which the procedure is available. A calendar is displayed for the selected site. Days with available appointments are identified in color. Clicking on

FIGURE 24.1

The opening screen: a listing of imaging modalities. Clicking on the desired modality produces a pull-down listing of examination types.

the hyperlink shows a listing of available appointments. A limited number of appointments are reserved for same-day use. These times are hidden until the day for which they are offered.

Selection of an appointment time secures the time, removes it from the list of available times, and completes the process. A reminder slip is printed for the patient with instructions for examination preparation. If 1 of our satellite facilities has been selected, driving directions are included.

This system functions independently of the RIS. To avoid conflicts, appointments made available on the order-entry system are blocked in the

FIGURE 24.2

A typical order screen, showing the categories of information:

special considerations, signs and symptoms, known diagnoses, and additional information. Selection of at least 1 sign, symptom, or known diagnosis is mandatory for scheduling to proceed.

RIS scheduling template. To prevent times from being unused, blocked times are released for general scheduling 24 hours ahead, and thus the majority of our order entry appointments are available at least one day into the future.

A small number of appointments is reserved for same-day availability.

Order-entry data are stored in a Structured Query Language (SQL) database. A Visual Basic script allows the transfer of information from Radi- ology Order Entry (ROE) to the RIS. Fields are transferred automatically by pressing a single function key, similar to a cut-and-paste operation, thereby drastically reducing the errors invariably associated with data entry.

Technical details such as assignment of proper examination codes and system resources are done manually by radiology department personnel.

A D VA N TA G E S

A C C U R A C Y

The order-entry system has resulted in important improvements in the accu- racy of the information provided to the radiology department. Although identification of the patient was rarely a problem with the paper system, doctor identification was much more problematic. This occurred because in our large system many physicians have similar names and because their written signatures were often hard to read. Electronic orders eliminate this problem.

Handwritten history presented problems for similar reasons and because the clerical staff who transcribed it might be unfamiliar with the medical vocabulary. Information absolutely necessary for performance of the test (side, level) might be overlooked. The mandatory fields of the order- entry system have made this a problem of the past.

Specific requests for the radiology department (such as “wet readings”) might be overlooked or their significance not comprehended. In addition, there was a further problem due to the fact that the written forms might not arrive in advance of the scheduled appointment.

C O N V E N I E N C E

Our system offers significant conveniences for the referring office and the patient. The alternative method for obtaining an appointment requires a telephone call to the radiology department. During peak hours, there may be a delay until a service representative is available. Information communi- cated by telephone may be incomplete or poorly understood. The telephone

communication is difficult to structure, resulting in information that might not be helpful for interpretation or not suitable for billing. Delays in the process often require the clinician’s office to schedule the appointment after the patient has left, leading to yet another communication problem, and an increased chance of a no-show.

Because the electronic system is fast and easy to use, patient appoint- ments tend to be arranged while the patient is in the physician’s office. This facilitates an interactive process that allows the patient to participate in selec- tion of the appointment, thus minimizing the need to reschedule and the risk of no-show.

Our referring offices prefer not to access multiple systems. Therefore, we provide access to reports through the order-entry system. An icon on the main page allows the referring office to view and print reports on their patients as well as the status of cases not yet performed or reported. Reports not previously viewed by them are searchable separately from those already seen, helping them to keep track of patient flow.

Although we have not as yet done this, in principle, some appointments (such as screening mammography) could be scheduled directly by the patient.

There are also significant advantages for the radiology department.

The most obvious advantage is that less time is needed to schedule an appointment by ROE than is needed to schedule an appointment by tele- phone. Therefore, fewer service representatives can schedule more proce- dures. In addition, the clerical function of entering data into the RIS takes place without delaying the referring office or patient.

Perhaps less obvious is the fact that the order-entry system becomes a useful conduit for information concerning radiology services. We use banners to announce the availability of new sites and new procedures [such as positron emission tomography-computed tomography (PET-CT)] and to provide tips for earliest appointments. For example, banners have been used to indicate that the earliest appointments for a particular type of exam are available at a particular satellite center. In addition, the choice of defaults helps to guide the selection of appointments to those sites with greatest availability. Finally, because it keeps track of cancellations and rescheduled procedures, the order- entry system provides important insight into the ways in which different refer- ring practices use (and misuse) our scheduling service. This knowledge has proven valuable in our education and marketing operations.

R E Q U I R E D I N F O R M AT I O N

The era of managed care has brought about specific information require- ments that are often extraneous to the traditional care process. For example,

to submit a bill for diagnostic imaging services, an ICD-9 code must be pro- vided. The ICD-9 code classifies the patient abnormality (a sign, symptom, or pathological state). In our experience, it has been impossible to educate the referring offices to the need for specific information that might be used for ICD-9 coding. Prior to the order-entry system, large numbers of requests continued to arrive with only the name of the condition that was being sought (e.g., “rule out tumor”) but lacking any information concerning patient complaint.

In addition, certain insurance plans require precertifications for certain procedures and provide the precertification based on clinical information.

The order-entry system ensures that the required information is collected and can be provided in electronic form should the insurance plan be willing to accept it.

H E A LT H I N S U R A N C E P O RTA B I L I T Y A N D A C C O U N TA B I L I T Y A C T O F 1 9 9 6

We believe that the electronic order-entry system represents a clear improve- ment in compliance with the Health Insurance Portability and Accountabil- ity Act of 1996 (HIPAA). Unlike our prior telephone-based scheduling system, the identification of the user is verified through a secure identifier (ID). Report-viewing privileges are limited to those doctors for whom sched- uling is performed. Although our system permits adjustments to the list of physicians for whom scheduling and report viewing are performed, logs are maintained of each interaction with the system, and inappropriate use can be identified.

S P E C I A L C A PA B I L I T I E S

Several additional special capabilities of electronic order entry should be noted. Decision support (advice about the appropriate use of imaging studies) can be provided at the time the examination is requested. Our system provides a “utility score” for the requested examination based on the history provided, similar to the American College of Radiology appropriateness cri- teria. This function is targeted to the physicians who use the system, as cler- ical staff are not at liberty to change orders and are unlikely to serve as conduits for this type of advice. It is too early to determine what effect, if any, this information may have on clinical practice.

In addition, our system provides information concerning potential duplication. If a patient has had a similar examination within the past month, a warning is displayed on the ordering screen. Similar examinations are not necessarily of the same type. For example, an alert concerning possible dupli- cation would appear if a CT scan of the head is requested when an MRI of the head had recently been done.

P R O B L E M S

As the use of the electronic system has grown, it has been necessary to allo- cate a steadily increasing fraction of the potential times to it. Because we lack a direct interface to the RIS, this requires continual balancing.

Radiologists have occasionally complained that the histories provided by the checklists sound generic. It has also been suggested that the check- lists are too easy to use and that perhaps unqualified personnel are taking the “path of least resistance,” resulting in histories that may not be accurate.

It is difficult to verify these concerns or to determine whether similar issues existed prior to order entry; however, ongoing surveillance of the quality of information is required.

An unanticipated source of resistance has been from within the radiol- ogy department. Modality managers may regard the order-entry system as lessening their control over their environment. By demystifying the sched- uling process, the role of the expert is diminished. Further, the ability to do favors for colleagues by providing access to limited appointment times is a source of pride and power, especially in an environment of scarcity.

T H E F U T U R E

The development of large healthcare networks and the increasing growth in imaging volume have undermined the type of personal referrals that once formed the basis of radiology practice. Radiology staff, and even the radiol- ogists, may not know the physicians who send patients. Indeed, in some larger practices, radiology office staff may not even know their own radiol- ogists. Multiple physicians may have the same or similar names, especially in large academic centers. Knowledge of medical terminology may be limited, leading to misspelled or even incomprehensible requests. Such trends will probably continue, making development of sophisticated knowl- edge-based, error-resistant systems ever more important.

It has become increasingly clear that tight integration of information systems is essential to capture their full benefits. For example, use of a

“broker” to coordinate Digital Imaging and Communications in Medicine (DICOM) images stored on picture archiving and communication systems (PACS) with patient information in the RIS introduces complexity that may result in use of outdated information. Newer system designs are tending to incorporate the broker function directly into the RIS. Ideally, the order-entry system should communicate directly with the RIS. In the near future, our RIS will likely be able to handle such interaction, thereby simplifying the whole process even further.

Implementation of a computerized order-entry system in a neonatal intensive care unit has already been shown to shorten the radiology response time (interval between order and image display) by almost 25%. Integration of technology will bring many further gains. Doubtless the future evolution of continuous speech recognition systems will include order entry, making these systems even faster and more convenient.

As progress is made in coordination of the components, there will be improved understanding of the possible failure points, leading to develop- ment of system tools that understand and monitor information flow.

Perhaps, as reality comes closer to concept, radiology order-entry systems may be integrated with electronic patient records, appropriateness criteria, and practice guidelines. Such computer-based practice guidelines might also include additional didactic material, such as images, videos, sounds, simulations, and links to bibliographic databases. Given patient data, these future systems might even select the most appropriate imaging study automatically.

◗ REFERENCES

Clark KW, Melson DL, Moore SM, et al. Tools for managing image flow in the modality to clinical-image-review chain. J Digit Imaging. September 2003;16(3):

310–317.

Cordero L, Kuehn L, Kumar RR, Mekhjian HS. Impact of computerized physician order entry on clinical practice in a newborn intensive care unit. J Perinatol. Feb- ruary 2004;24(2):88–93.

Langer S. Radiology speech recognition: workflow, integration, and productivity issues. Curr Probl Diagn Radiol. May–June 2002;31(3):95–104.

Mulvaney J. The case for RIS/PACS integration. Radiol Manage. May–Jun 2002;

24(3):24–29.

St. Anthony’s Guide to Code Linkage, CPT and ICD-9 CM Code Connection. St.

Anthony’s Publishing; January, June 1997.

Tjahjono D, Kahn CE Jr. Promoting the online use of radiology appropriateness criteria. Radiographics. November–December 1999;19(6):1673–1681.