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Distributed computing environment complicates radiology QA

Demands for patient throughput, remote readings of radiology digital images make quality-assurance thorny. IT leaders can assist radiologists in building better processes.

CHICAGO -- Digital imaging, versus the film technology it replaced, has many upsides for radiologists, among them searchable databases, images that can be instantly sent around the world via the Internet, the ability to edit and manipulate scans, and no toxic chemicals. Workflow automation's another huge benefit, offering radiology practices the ability to have a technician create a scan with the patient in one place, and the radiologist reading it half a mile -- or half a continent -- away.

However, remote reading comes at a price, said Radiological Society of North America's RSNA 2011 annual meeting presenter Kevin McEnery, M.D., associate division head for informatics at MD Anderson Cancer Center in Houston. It greatly complicates quality assurance (QA) programs for radiology practices. Making sure digital images are consistent and readable -- along with creating a formal, standardized mechanism for technicians and radiologists to communicate with one another in order to rectify mistakes, cut down on rescans and prevent future bad scans -- can be difficult when geography separates the two.

Furthermore, this distributed computing environment introduces new complications unknown in the days of film, such as how different monitors on which practitioners view images (or different room-lighting situations) can make images appear differently. In addition, radiology information systems (RIS) and picture archiving and communications systems (PACS) aren't always interoperable, making it difficult for radiology leaders who don't have good IT support to survey images across their enterprise to determine if their quality goals are being met or, in some cases, to even set benchmarks from which to begin quality measurement.

Economics can hinder radiology QA, too

Finally, maximizing patient throughput is a top priority for radiology practices, said co-presenter Jeff Shepard, senior medical physicist at MD Anderson.

Not only do bottom-line oriented hospital leaders demand it to maintain revenue streams, but patients do, too. MD Anderson does 600,000 radiology studies a year, 80% of them outpatient. Many patients travel to the facility to get their scans done. When technical delays due to imaging quality problems prolong their stay in Houston, they get testy -- and demand compensation if it spills into missed flights and extra days.

"When they're coming in from Saudi Arabia, that can get expensive," said Shepard as he outlined his facility's radiology QA program. That involves standardizing the language of QA queries and answers, streamlining communications between all parties involved in making an image, and surveying the PACS system to compare performance year-over-year, which is most effective when a "frequent flyer" patient has 10 years' worth of scans to compare.

"I would argue, in the age of PACS, that it's easier to maintain image quality than it was in the film-based era," McEnery added. He said the ability for a technologist to quickly access and view a patient's previous studies -- as well as the rapid evolution of PACS databases and RIS systems to give better and better search results -- are two areas where digital imaging clearly holds advantages over old analog film, despite the challenges of a distributed computing environment.

IT can help set up active network monitoring so radiology QA leaders can watch displays and scanners for issues such as machines going offline or getting out of calibration.

But most radiology practices -- whether they're standalone or a hospital department -- don't have the resources to "roll their own" systems as MD Anderson did. Its system involves active network monitoring to make sure imaging devices (including LCD displays) are online and functioning properly, as well as Web-based utilities that radiology team members with programming expertise and interest in the problem-solving process managed to write in their spare time.

IT, radiology can build QA systems together

Over time, McEnery believes, RIS vendors will build features into their software to support more robust QA programs. This will happen, he said, as awareness and research around certain issues such as patient lifetime radiation doses from radiology images become more significant quality-of-care metrics. (As it turns out, cutting down on radiology retakes can help manage that.)

"Pressure vendors over time in order to get these tools into their products," McEnery said, noting that one does not need a large staff to make a large impact.

For now, however, radiology practices can get the ball rolling themselves, with initiatives as small as email QA protocols, he said.

That's where IT staffs, which McEnery called the "unsung heroes" of MD Anderson's radiology QA initiative in a conversation with after his presentation, come in. Not only can IT staff interconnect RIS and PACS systems for radiologists and give them the ability to survey images from several "silos," they can also help build communications systems. These can be as simple as a paper or email form that's scanned to a database or as elaborate as a Web form system that links to the image being discussed.

For more ambitious radiology practices, IT can help set up active network monitoring so radiology QA leaders can watch displays and scanners for issues such as machines going offline or getting out of calibration. The American Association of Physicists in Medicine (AAPM)Task Group 18 currently is adopting comprehensive standards, benchmarks, recommended testing procedures and best practices for calibrating displays, which turns out to be a complicated process. However, technicians can perform some of the work, including quick tests when the display they're using sends an alarm that it might be incorrectly rendering images on screen.

It's also important to get all parties communicating. Though this is primarily radiology's responsibility, IT can play a role here by documenting that communication. This gives the department a means of diagnosing problems and giving feedback to frontline techs, whose participation is vital but won't be enthusiastic if their opinions and suggestions aren't being heard.

Let us know what you think about the story; email Don Fluckinger, Features Writer.

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