Implementation of Online Tool for Computed Tomography Exam Protocoling by Radiologists: Challenges and Lessons Learned

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Implementation of Online Tool for Computed Tomography Exam Protocoling by Radiologists: Challenges and Lessons Learned Jacqueline C. Junn, MD, Brent P.

1 Implementation of Online Tool for Computed Tomography Exam Protocoling by Radiologists: Challenges and Lessons Learned Jacqueline C. Junn, MD, Brent P. Little, MD, Phuong- Anh Duong, MD. Department of Radiology and Imaging Sciences Emory University School of Medicine American College of Radiology Meeting May, 2016

2 DISCLOSURES None

Background: Rationale Selection of appropriate CT protocols is instrumental in

Previously, protocolling done via multifaceted approach, which propelled the need

may increase eﬃciency and reduce interruptions.

3 Background: Rationale Selection of appropriate CT protocols is instrumental in tailoring diagnostic examinations to patients. Previously, protocolling done via multifaceted approach, which propelled the need for developing a protocol tool linked to the electronic ordering system and PACS may increase eﬃciency and reduce interruptions. Additionally, more streamlined protocolling would increase resident s involvement in exam protocolling to provide additional educational opportunities.

Background: Streamlining Radiologist- Driven Protocoling Process Implementation of Online Protocolling Tool Background Goals Proposed Action Prior to implementation and integration of an online

Methods were not standardized across divisions.

communication of protocols to technologists Standardize protocols to ensure uniformity of protocol naming and protocol specifications Implement standardized protocolling into daily workflow Educate

4 Background: Streamlining Radiologist- Driven Protocoling Process Implementation of Online Protocolling Tool Background Goals Proposed Action Prior to implementation and integration of an online protocolling tool integration into workflow, a variety of protocolling mechanisms were utilized, including written protocols and instructions delivered over the phone. Methods were not standardized across divisions. Pitfalls: Miscommunication a problem Missing protocols common Protocols often not standardized Documentation difficult to maintain Streamline protocolling process to increase efficiency Provide fast communication of protocols to technologists Standardize protocols to ensure uniformity of protocol naming and protocol specifications Implement standardized protocolling into daily workflow Educate trainees regarding appropriate protocolling Provide documentation of protocolling to enable feedback on appropriateness of each protocol Research and deploy a web- based protocolling tool that is integrated into the radiology information system (RIS) Leverage the tool to increase participation of residents and faculty in protocolling Integrate protocolling more efficiently into daily workflow of residents and faculty Provide training to residents and faculty in using the tool Provide feedback to trainees about appropriateness of protocolling

5 Implementation and Tool Evaluation Implementation of such a tool requires planning and education. Each division standardizes protocols and protocol names. Education on protocols and how to use protocol tool for residents using online module. IT department in charge of adding protocols to a pre- existing protocolling tool within the Radiology Information System (RadNet, Cerner Corp). Piloted protocol tool in one division (Cardiothoracic) Evaluated compliance and impact on appropriateness of exam protocol

Implementation of Online Protocol Tool Standardizing Protocol * Create standard protocol for different indications per department Standardizing Protocols Each division approved standard protocols for

via Radnet * Incorporation of protocolling into daily workflow CHC1 CT*Chest*without*Contrast CH1_CHST_WO* CHC2 CT*Chest*with*contrast CH2_CHST_W* CHC3 CT*Chest*Pulmonary*Embolism CH3_CHST_W_PE CHC4

6 Implementation of Online Protocol Tool Standardizing Protocol * Create standard protocol for different indications per department Standardizing Protocols Each division approved standard protocols for different study indications Currently, 114 Cardiothoracic, abdominal & pelvic, & neurology protocols are included in the protocolling system CHEST*PROTOCOLS: SHORT*NAME Developing Protocolling Tool via Radnet * Incorporation of protocolling into daily workflow CHC1 CT*Chest*without*Contrast CH1_CHST_WO* CHC2 CT*Chest*with*contrast CH2_CHST_W* CHC3 CT*Chest*Pulmonary*Embolism CH3_CHST_W_PE CHC4 CT*Chest*without*High*Resolution CH4_CHST_WO_HI_RES CHC5 CT*Chest*without*lung*cancer*screening CH5_CHST_WO_LUNG_SCREEN CHC6 CT*Chest*without*superdimensional CH6_CHST_WO_SUPERD CHC7 CT*Chest*without*airways CH7_CHST_WO_AIRWAY* CHC8 CT*Chest*without*tracheomalacia CH8_CHST_WO_TRACHEOMALACIA CHC9 CT*Chest*without*low*dose*nodule CH9_CHST_WO_LO_DOSE_NODULE VASCULAR*PROTOCOLS: VCC1 CTA*CHEST*W VC1_CTA_CHST_W* VCC2 CTA*CHEST,*ABDOMEN,*(+PELVIS)*WITH VC2_CTA_CAP_W VCC3 CTA*ABDOMEN*AND*PELVIS*W VC3_CTA_ABD_PEL_W_AORTA VCC4 CTA*CHEST*ABDOMEN*(AND*PELVIS)*DISSECTION*WITHOUT*AND*WITH VC4_CTA_CAP_WO_W_DISSECTION VCC5 CTA*CHEST*ABDOMEN*DISSECTION*WITHOUT*AND*WITH VC5_CTA_CHST_ABD_WO_W_DISSECTION VCC6 CTA*ABDOMEN*(+PELVIS)*ENDOGRAFT*WITHOUT*AND*WITH VC6A_CTA_ABD_WO_W_ENDOGRAFT** VCC7A CTA*CHEST*ENDOGRAFT VC7A_CTA_CHST_ABD_WO_W_ENDOGRAFT VCC7B CTA*CHEST*ABDOMEN*ENDOGRAFT VC7B_CTA_CHST_ABD_WO_W_ENDOGRAFT VCC7C CTA*CHEST*ABODOMEN*PELVIS*ENDOGRAFT VC7C_CTA_CHST_ABD_PEL_WO_W_ENDOGRAFT VCC8 CTA*PELVIS*LOWER*EXTREMITY*RUNOFF VC8_CTA_W_PEL_LE VCC9 CTA*ABDOMEN*PELVIS*LOWER*EXTREMITY*RUNOFF VC9_CTA_W_ABD_PEL_LE VCC10 NONCONTRAST*TAVI VC10_CHST_WO_ABD_PEL_TAVI VCC11 CTA*CHEST*W*OUTLET VC11_CTA_CHEST_W_OUTLET_OBSTRUCTION VCC12 GATED*PROTOCOLS: Summary of cardiothoracic study protocols GAC1 CALCIUM*SCORE GA1_CALC_SCORE GAC2A CORONARY*ARTERY*CALCIUM*SCORE*AND*CTA_PROSPECT GA2A_CTA_COR_ARTS*CALC_SCORE*_WO_W_PROSPECT* GAC2B CORONARY*ARTERY*CALCIUM*SCORE*AND*CTA_RETROSPECT GA2B_CTA_COR_ARTS*CALC_SCORE*_WO_W_RETROSPECT GAC3 GATED*CHEST*CTA GA3_CTA_CHST_W_GATED GAC4 GATED*TAVI GA4_CTA_CHST_W_GATED_TAVI* GAC5A CORONARY*ARTERY*CTA*PROSPECTIVE GA5A_CTA_CHST_W_COR_ARTS_PROSPECT GAC5B CORONARY*CABG GA5B_CTA_CHST_W_COR_ARTS_RETRO GAC6 TRIPLE*RULE*OUT GA6_CTA_CHST_TRIPLE_RO_W* GAC7A CARDIAC*STRUCTURE*MORPHOLOGY*CCPROSPECTIVE GA7A_CTA_CHST_W_HEART_STRUCT_MORPHCRETRO GAC7B CARDIAC*STRUCTURE*MORPHOLOGY*FUNCTIONCCRETROSPECTIVE GA7B_CTA_CHST_W_HEART_STRUCT_MORPH_PROSPECT* GAC8 GATED*CHEST*WO GA8_CHEST_WO Education * Video module on how to use the tool *Educational conferences regarding different protocols Example of Cardiothoracic vascular study for dissection includes study indication and series to be performed VCJ4'AND'VCJ5 CTA*Dissection*(chest/abd/pel*or*chest/abd) Indications # Series*Name Comments dissection'or'intramural'hematoma 1 scout AP'and'lateral 2 ax'without'(chest'only) 2.5'mm'(scan'chest'only'to'renal'arteries) Administer*IV*contrast:*Omnipaque*350*at*4cc/sec 3 ax'arterial' 1.25'mm'x'1.25'mm'(C/A/P'or'as'ordered) 4 sag'(arterial) 2.5'mm 5 cor'(arterial) 2.5'mm 6 ax'mips 7'mm'thickness'at'2.5'mm'intervals'(chest'only) 7 dose'report

Process for Radiologists Implementation of Protocolling

Ordered studies can be found under the protocol tab where

Radiologists can view the study indication & any special

order every morning & throughout the day to ensure proper

7 Process for Radiologists Implementation of Protocolling via RadNet 1. Ordered studies can be found under the protocol tab where radiologists can vet the order 2. Radiologists can view the study indication & any special requests Daily task Radiologist reviews and vets each order every morning & throughout the day to ensure proper studies have been ordered 3. If needed, protocolling radiologist can access patient s electronic medical record via the same platform

8 Process for Radiologists: gathering information 4. Check for patient s allergies prior to protocolling, especially studies with contrast 5. Dropdown menu with all available protocols. Select the appropriate study. Training Radiologists were trained by online modules on how to use the RadNet protocolling tool 6. After selecting the appropriate study, click save.

9 Evaluation of Protocolling Tool Approximately 1,700-2,000 studies to be protocolled per month in our Cardiothoracic Division. We evaluated for utilization and impact on protocol appropriateness using CT cardiovascular studies (aneurysm, dissection, post endograft, lower extremity vascular runoff, and transcatheter aortic valve insertion). We included vascular studies that were to be read by our Cardiothoracic Division. Checked each post- endograft examination for appropriate protcolling (ex: including delayed phase to properly evaluating for endoleak). Between the pilot phase (2/16/2015-3/15/2015) and full implementation phase (11/1/ /30/2015), residents were trained in using the protocolling tool, and educated on how to select proper studies for different study indications. We evaluated the percentage of vascular studies being protocolled. When the studies were not protocolled, studies ordered by the clinicians were defaulted (ex: dissection protocol)

10 Evaluation of Protocolling Tool Early Implementation period 118 vascular studies included 16 of 118 (13.6%) appropriately protocolled by radiologist or resident Total of 23 endograft studies 3 mentioned endograft in indication 11 studies incorrectly ordered by ordering physician 6 protocolled (2 appropriately protocolled by radiologist) Full Implementation period 114 vascular studies included 67 of 114 (59%) appropriately protocolled by radiologist or resident Total of 21 endograft studies 3 mentioned endograft in indication 15 studies incorrectly ordered by ordering physician 14 protocolled (9 appropriately protocolled by radiologist) Only 6 of 43 post endograft studies (both early and full implementation periods) included prior surgical history Interval improvement in number of studies being protocolled with more appropriate protocolling with protocolling education

11 Conclusions CT exam protocoling using a protocol tool Facilitates rapid and effective protocoling by radiologists May result in fewer calls or interruptions Tailors the exam to the indication, especially for cases where the history is not provided and needs to be researched. Needs planning to integrate into radiologist and technologist workflow Requires education for trainees to understand the protocols, the process, and the tool

SUBJECT: Importing of Patient Images Effective: 1/2013 Reviewed: 04/2015 APPROVED BY: Director of Radiology Page 1 of 6. Importing of Patient Images

SUBJECT: Importing of Patient Images Effective: 1/2013 Reviewed: 04/2015 APPROVED BY: Director of Radiology Page 1 of 6. Importing of Patient Images APPROVED BY: Director of Radiology Page 1 of 6 Importing of Patient Images Purpose: In order to ensure that physicians have ready access to outside images and continuity of care is maintained, the Radiology