Has imaging become too effective?

Adrian Dixon

Professor Adrian Dixon has a worldwide reputation as an academic and a radiologist and has published extensively on body and musculoskeletal CT and MR imaging.

He will deliver the BIR Toshiba Mayneord Eponymous Lecture called “Has imaging become too effective?” at UKRC on 7 June 2016 at 13:00.

Read this fascinating interview with him and get a taster of this “not-to-be-missed” presentation.

You will be delivering the BIR Toshiba Lecture at UKRC this June. Your lecture is called “Has imaging become too effective?” Can you give us a “taster” of what you mean by this?

“You should say what you mean!” as the March Hare said in “Alice’s Adventures in Wonderland”.

What do people mean by “effective”? Effectiveness is only an appropriate term if qualified. Modern imaging certainly is effective at increasing the diagnostic confidence about a diagnosis and excluding certain diagnostic possibilities. It has taken a long while to prove that it is effective in saving lives. It has become so effective that, in many conditions, an image can be rendered to make the diagnosis obvious to the man in the street.

And clinicians now tend to refer for imaging without stopping to think! It has also become so effective in demonstrating probably innocuous lesions that the worried well can become even more of a hypochondriac! In some societies this can lead to over usage, excessive radiation exposure and increased costs.

If imaging is “too effective” – is radiology still a worthwhile career choice?

Yes! It is the most fascinating of all medical careers and every day a radiologist should see something that he or she has never quite seen before. The radiologist is the ultimate medical detective and cannot conceivably get bored. Indeed radiologists get reimbursed to solve crossword puzzles on elaborate play stations!

What have been the three biggest challenges for you in your career?

Radiologists have had to learn and relearn their skills at frequent intervals during their careers. Radiology will only survive as a specialty if the radiologist knows more about the images, the technical aspects and the interpretative pitfalls than their clinical colleagues.

Did you ever meet Godfrey Hounsfield (inventor of CT imaging) and what were your memories of him?

opening of scannerI did indeed meet Sir Godfrey on numerous occasions. His humility and “boffin style” of science greatly appealed. Some of the stories at the numerous events surrounding his memorial service were truly fascinating, including his inability to accept any machine which he could not understand without taking it to bits and then reassembling it!

 

Given the financial pressures on healthcare, will the required investment in the latest imaging technology be affordable?

Some of the developments in personalised medicine may be unaffordable. Generic contrast agents will continue to be used in large volumes. The cost of creating “one off” agents may prove unjustifiable.

Why would you encourage someone to join the BIR?

Because of the fun of interdisciplinary discussion and the pride of being a small part of the oldest radiological society!

Does spending more money on equipment mean a better health service?

I passionately believe that prompt access to imaging makes a major contribution to excellent healthcare. But that does not necessarily mean that every hospital has to have every machine at the top of the range. A rolling programme of equipment replacement is an essential part of delivering a high-quality radiological service.

The most difficult thing I’ve dealt with at work is…

An electrical power cut during the middle of a tricky adrenal CT-guided biopsy!

If Wilhelm Roentgen could time travel to Addenbrooke’s hospital, what would he be most impressed with?

The sheer size and the number of staff of the radiology department!

When its 2050, what will we say is the best innovation of the 21st century in healthcare?

Data mining and health statistics.

Who has been the biggest influence on your life? What lessons did that person teach you?

All my previous bosses have influenced my career. I have learnt something from each of them. All of them stimulated me to ask the question “why are we doing things this way”? “Can it be done better”?

My proudest achievement is…

Helping to make the Addenbrooke’s Radiology department one of the most modern in the UK.

What advice would you pass on to your successor?

Never give up, try, try and try again and remember “the more you practice, the luckier you get”.

What is the best part of your job?

That I have been lucky to have had a succession of challenges in the various roles that I have held, all of which have kept me on my toes.

What is the worst part of your job?

Leaving salt of the earth friends as I have moved from role to role.

If you could go back 20 years and meet your former self, what advice would you give yourself?

Do not worry so much – it will all be alright on the night.

Adrian Dixon

Adrian Dixon

What might we be surprised to know about you?

That I support Everton Football Club.

How would you like to be remembered?

For influencing the careers of younger colleagues – hopefully to their benefit!

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Professor Dixon will deliver the BIR Toshiba Mayneord Eponymous Lecture called “Has imaging become too effective?” at UKRC on 7 June 2016 at 13:00.

Book your place at UKRC (early bird rate ends 15 April 2016)

 

Toshiba-leading-innovation-jpg-large Thank you to Toshiba for supporting the BIR Mayneord Eponymous Lecture

 

 

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Is your radiology department part of your hospital’s disaster management plan?

Ronald Bilow

Dr Ron Bilow

When Dr Ron Bilow experienced a major emergency in his hospital, it got him thinking about the role of the radiology department.

Here he explains what led to the radiology department becoming an integral part of the organisation’s disaster management plan.

 

Sports spectators

 

What would you do if large number of these sports spectators (right) suddenly arrived at your hospital after a disaster occurred at the event?

What arenas can you identify in your vicinity that may serve as a gathering site for a large number of people? This could be in the form of sports stadiums, performance halls or amphitheaters, schools, shopping districts, hotels, airports, even restaurants and movie theaters. Is there a public transportation system near you? Are there elevated roads or railroad tracks nearby? Do you live in an area that is prone to earthquakes, fires, tornadoes, tsunamis or landslides? Whether it be from a natural event, a faulty device or other accident, or intentional harmful acts by one or more persons (as shown in the photo below) you probably need to be prepared to handle a rapid surge in patient influx at your institution.

Crowd scene at Boston marathon bombing

Allow me to continue with this brief illustrative story: I was covering the emergency radiology service at my level one trauma center one day when the administrators received a telephone call alerting us to a roof collapse, resulting in an estimated 100 potentially injured patients. What I witnessed was, simply put, amazing…efficiently coordinated preparation for the worst scenario imaginable.

The nursing staff, emergency physicians, emergency medical technicians (EMTs), clerical staff and housekeepers began preparing the emergency center (EC) for a high volume of patients by clearing out those awaiting transfer to the operating room (OR) or hospital ward, or discharge home. Additionally, extra stretchers were brought into trauma bays and hallways, and each was stripped down, sanitized and made ready with clean linens. Equipment was organized and put away, extra IV poles and blood product pumps were brought in, and each room was either verified ready or had its depleted stock replenished. In a matter of perhaps 15-20 minutes, the EC was ready to handle the onslaught. In short, predefined protocols were rapidly implemented during the incident, and most of the people knew their role.

Boston Marathon 2

Watching rescue helicopters from my office

Throughout the process, I stood in awe, yet somewhat disappointed…and even a bit uncomfortable…that I didn’t have a role…or, if I did have a role, I didn’t know what it was.

It got me thinking…as a radiologist, what is expected of me? What am/was I supposed to be doing to help prepare? What will be my role when the patients arrive? Is it merely to read whatever imaging exams are obtained, or is there some additional way I can help manage the problem?

It is clear from the above scenario, that our hospital has a plan for how best to handle the increased load after a mass casualty incident. This is known as a disaster management plan (DMP). In order to achieve that, leaders had to consider various scenarios and determine how the workers in each department should respond. It was also clear that the planning went much further than the EC. Phone calls were made to the receiving ward’s charge nurses alerting them that patients were coming out of the EC due to the pending influx of new trauma patients, per the hospital DMP. The OR was notified that they would receive patient’s waiting for surgery in their holding area. In short, things ran very smoothly, without pushback from the receiving services. Perhaps even additional staff were called in from home by one or more departments?

Whatever the case, it was also glaringly obvious that the radiology department had been left out of the planning, and in fact, nobody in radiology services had any idea how to handle or respond to a MCI and the resultant DMP activation. And the truth is, without a radiology department DMP, the hospital’s plan will fail. Imaging services will be rapidly overwhelmed due to lack of adequate resource management, and patients will suffer. It needs to be determined ahead of time how to decrease wait time for imaging services, speed up delivery of each examination, how reports will be disseminated and to whom, and who will do what work. This simply cannot be achieved without prior analysis and planning.

It is common knowledge that imaging has been increasingly used over the past few decades in the evaluation of critically ill patients, and for the most part, has become the standard of care. Through drills and real life experiences, researchers have shown how imaging services can become a severe bottleneck in implementing care during the hospital phase of a mass casualty incident. Thus, it seems essential to include technical and physician leaders from the radiology department in planning how best to manage the surge in patient volume after a disaster occurs. In our institution, we have begun the process of being incorporated in our hospital DMP, and hope to expand our role to help facilitate further excellence in the city-wide disaster response. Is it time for you to do the same?

About Dr Ronald Bilow

After graduating from The Chicago Medical School in 1996, Dr Ronald Bilow completed his residency in diagnostic radiology at Santa Barbara Cottage Hospital (Santa Barbara, California), and subsequently underwent fellowship training in Emergency Radiology at The University of Texas, Health Science Center in Houston (now the McGovern Medical School), and Musculoskeletal Radiology at the University of California, San Diego. He currently holds the position of Assistant Professor on the McGovern Medical School faculty in Houston, Texas, where he teaches medical students and both emergency medicine and diagnostic radiology residents and fellows. Dr. Bilow performs his clinical duties primarily at a level one trauma center, Memorial Hermann Health System – TMC, in Houston, Texas. He was recently appointed as radiologist member to the joint University of Texas, McGovern Medical School – Baylor University Medical School Disaster Management Planning Committee. He has been a Fellow Member of the ASER (American Society of Emergency Radiology) since 2005, and has served in numerous leadership roles including Case of the Day Director, Education Committee Chair/Co-Chair, Director at Large, Treasurer, Bylaws Committee Chair and Member, and Strategic Planning Committee Member. He has also held membership on the Annual Meeting Program Planning and Scientific Program Committees.

IMAGES

Figure 1. Photo: Nathan Bilow Photography.

Figure 2. Open source photo.

Figure 3. Photo taken by author, Ron Bilow, from his office window

 

Making the case for radiographer reporting

SONY DSC

With a steady and sustained rise in imaging workloads driven by an ageing population, new and evolving technologies, and a drive for patient-focused care, radiology departments are turning to new ways to provide services. Nick Woznitza, Clinical Academic Reporting Radiographer at Homerton University Hospital, east London, and Canterbury Christ Church University, Kent, makes the case for radiology departments meeting these ever-increasing demands through radiographer reporting.

Using the example of his experience in the neonatal department of Homerton University Hospital he explains how, with robust research and training, and the appropriate use of skill mix, departments can offer a safe, efficient and patient-focused service.

Expansion of the neonatal medicine department at Homerton produced an increase in plain imaging workload and, coupled with a shortage of consultant paediatric radiologists, meant that the neonatal X-rays did not receive a timely definitive radiology report. The neonatal unit is a large, tertiary referral facility with 46 cots, 900 admissions and 13,600 cot/days per annum in 2013–2014. In order to provide an optimal service to these vulnerable patients, it was agreed to develop a radiographer-led plain imaging neonatal reporting service.

A bespoke, intensive training programme was designed in collaboration with radiology and neonatal medicine at Homerton, Canterbury Christ Church University and the paediatric radiology department of the Royal London Hospital. The radiographer was already an established reporting radiographer, interpreting skeletal and adult chest X-rays in clinical practice, so the training programme focused on the unique physiology and pathology of neonates. Training consisted of self-directed learning, pathology and film viewing tutorials, practice reporting, and attendance at the neonatal X-ray meeting at the Royal London Hospital. This immersive experience was achieved via secondment for one and a half days a week.
Upon qualification of the reporting radiographer, all reports were double read by a consultant paediatric radiologist, to successfully manage the transition into practice whilst maintaining patient safety in line with best practice recommendations.

To ensure that the performance of the trained reporting radiographer was comparable to that of a consultant paediatric radiologist a small research study was conducted (Woznitza et al, 2014), supported by research funding from the International Society of Radiographers and Radiographic Technologists (ISRRT). This study confirmed only a small number of clinically significant reporting radiographer discrepancies (n = 5, 95% accuracy), comparable to the performance of the paediatric radiologists. This study provided further evidence that the introduction of radiographer neonatal plain imaging reporting has not adversely impacted patient safety or care.

Activity figures (July 2011 – September 2014) were obtained from the radiology information system to determine the number of X-ray examinations performed and the proportion receiving a radiographer report. An average of 285 X-rays were performed each month, however, there was a marked increase in March 2012 from 158/month (July 2011 – February 2012) to 328/month (March 2012 – September 2014). The radiographer has made a sustained, significant contribution to the reporting service, interpreting an average of 92.5% of the X-ray examinations and responsible for >95% of examinations in 20 of the 36 months.

Building on the collaboration between radiology and neonatal medicine, a weekly neonatal X-ray meeting was introduced. Facilitated by the reporting radiographer and paediatric radiologist, this forum has increased radiology–clinician engagement and in turn patient care, facilitated discussions and acts as an excellent educational resource. Recognising the importance of this meeting, the senior neonatal clinicians requested that the reporting radiographer convene the meeting when the paediatric radiologist is absent on leave.

The introduction of a radiographer neonatal X-ray reporting service demonstrates that, with collaboration and support, novel approaches can help provide solutions to increasing activity in radiology in an effective, efficient and patient focused manner without compromise on patient safety. Collaboration and team work are fundamental when undertaking service delivery change. The support of both the radiology department, under the leadership of Dr Susan Rowe, and the neonatal unit, led by Dr Zoe Smith with mentorship from Dr Narendra Aladangady, has been essential in the success of this service.

Nick Woznitza biography
Nick qualified as a diagnostic radiographer from the University of South Australia and, following several roles in rural and remote Australia, moved to the UK in 2005.

An accredited consultant radiographer with the College of Radiographers, Nick reports a range of plain imaging examinations including skeletal, chest and neonatal X-rays. He has recently taken up a clinical academic radiography role at Homerton University Hospital and Canterbury Christ Church University, with this blended role facilitating image interpretation teaching to radiographers and other health professionals and his research into the accuracy and impact of radiographer reporting.

Reference
Woznitza N, Piper K, Iliadis K, Prakash R, Santos R, Aladangady N. Agreement In Neonatal X-ray Interpretation: A Comparison Between Consultant Paediatric Radiologists and a Reporting Radiographer. International Society of Radiographers and Radiographic Technologists 18th World Congress. June 2014; Helsinki, Finland, 2014.

Skill mix in radiology: a personal tale

Chris Loughran BIR blogWhen Dr Chris Loughran published research into the benefits of trained radiographers reporting trauma radiology he was accused of committing professional suicide. But he was on a mission to spread the word.

 

 

Years ago I was appointed as Clinical Director of Radiology. I knew nothing about management and thought I had better go and learn something. I enrolled at Keele University for a diploma course in Management in Radiology. In the second year I had to write a dissertation. Scratching around for something I was inspired by Prof. Roger Dyson to consider what he termed “Clinical Radiography”, a concept that encouraged radiographers to move from the production of diagnostic images only to one where they also interpreted them.

Some research was essential and I was able to cajole three radiographers into contributing to the research effort. The aim was to determine if the diagnostic performance of the radiographers in trauma radiology could be enhanced with training, to such an extent that they could report such radiographs to a high standard. We showed that they could and the research findings were subsequently published in the BJR.1 We took the plunge even before the paper was published and with the backing of the East Cheshire NHS Trust those radiographers started to report directly to the accident department. I believe we were the first in the country to do this. The backing of the Trust Board was sought, and was essential, to ensure that in the event of error we were covered. It fulfilled my belief that radiographers could employ their talents to a greater extent—for the benefit of the department, the hospital in general and, of course, the patients.

I felt as though I was now on a mission—time to spread the word and encourage other departments to work in a similar fashion. To this end I decided to seek out further interest at a local regional radiologists meeting. Naively, I thought my proposals to expand our local in house training programme to a more established and regional exercise would be welcomed. Less time spent by radiologists on an element of the work that many were reluctant to undertake combined with better service delivery to patients seemed like an unbeatable combination. I should have known better! I had never been shouted down previously (nor since) but was that afternoon. “You’re committing professional suicide !” one colleague ferociously remarked, he’s probably forgotten, I never have. The idea clearly touched many raw nerves. So I slunk away, cowed, feeling battered and rejected. What I couldn’t really get my head round was the absolute rejection of the idea when I knew so many departments were struggling with their workloads and so many radiologists complained about it.

Despite this rejection the radiographers themselves picked up on the idea and I was asked by many organisations to speak about the research and the concept in general. I particularly remember one meeting in Nottingham where I spoke to a crowded lecture theatre. I was introduced by a radiologist, the talk went well and he very kindly remarked afterwards that I was so convincing he would buy a second hand car from me!

Later I was invited to help establish a course in radiographer reporting at Canterbury, Christ Church College. We agreed a schedule for the course and associated examination. I was privileged to be an external examiner and was mightily impressed by the very high standard that many candidates attained. Radiologists had (until then) never been examined in trauma plain film radiology to the extent these candidates were.

Of course, similar training soon followed elsewhere and it now is established practice in many departments. Indeed it has gone further with radiographers reporting other examinations including CT head scans, for example. Moreover, many adverts for radiologist positions now highlight this practice as an inducement for candidates to apply for their posts. Its moved a long way since that regional radiology meeting all those afternoons ago.

Its taught me that its not only the truth that matters but also the diligence with which it is pursued. If you believe in something keep going! As Edward Bulwer-Lytton put it, “Enthusiasm is the genius of sincerity and truth accomplishes no victories without it”.

  1. Loughran CF. Reporting of fracture radiographs by radiographers: the impact of a training programme. Br J Radiol 1994; 67: 945–50. doi: 1259/0007-1285-67-802-945

About Dr Chris Loughran

I qualified in Liverpool in 1976 and have been pursuing radiology since 1978. I trained in radiology in Liverpool. After a 2-year stint as Consultant at Broadgreen Hospital I went to the USA for a year where I was Assistant Professor in The Medical University of South Carolina, Charleston, USA. Returning to England I took up post in Macclesfield where I have been since 1986.

In my time I have been Clinical Director, Postgraduate Tutor, Associate Medical Director and Chairman of the Medical Staff Committee. I was Chairman of the Northern Branch of the BIR and BIR council member some years ago. Now I work as a clinical radiologist and am so lucky that I still enjoy the speciality as much as I did all those years ago.

 

The advent of radiation protection through WWI radiology martyrs

Dr Adrian Thomas

As we commemorate the centenary of the outbreak of World War One and as we approach Armistice Day on 11 November, Dr Adrian Thomas, BIR Honorary Librarian, reflects on the huge impact that the WWI radiology martyrs had on the radiation protection standards we take for granted today.

 

Many things were to change in 1914 at the start of hostilities and were never quite the same afterwards. The old confidences were shaken.

One item that symbolizes this period for me is an old wrist watch given to me by Yvonne Beech. It was presented to Corporal Edward Wallwork RAMC (Royal Army Medical Corps). Wallwork was from Lancashire and had worked in the cotton industry; he came to London during the Great War, joined the RAMC and trained as a radiographer.

 

The wristwatch presented to radiographer, Corporal Walwork, by three London radiologists

The wristwatch presented to radiographer, Corporal Walwork, by three London radiologists

At the outbreak of hostilities the War Office requisitioned a newly completed five-storey warehouse, H.M. Stationery Office in Stamford Street, for a 1650-bed Red Cross military hospital. The hospital was close to Waterloo Station and was connected by a tunnel. The building today is part of King’s College London.

The silver Swiss wristwatch was presented to Wallwork by doctors Ironside Bruce (1879–1921), Stanley Melville (1867–1934) and George Harrison Orton (1873–1947).

2bThe three doctors had all served in the forces as radiologists. Before the war men wore pocket watches and only ladies wore wristwatches. It was said that a man would sooner wear a dress than a wristwatch! However, pocket watches were not practical in the trenches. The wristwatch is a typical good quality Swiss wristwatch from the end of the First World War period and the numerals and hands were designed to be filled with radium to create a luminous dial.

The presentation of the watch was as a token of appreciation for Wallwork’s work in the X-ray department of the King George Hospital from 1915 to 1919.

Patients rehabilitating at King George Hospital

Patients rehabilitating at King George Hospital

All of the three doctors were deeply involved in the BIR or its predecessor organisations and sadly all three suffered from radiation-induced disease.  Their names are recorded on the X-ray martyr’s memorial in the grounds of St George’s Hospital in Hamburg.

Ironside Bruce was on the staff of Charing Cross Hospital and the Hospital for Sick Children in Great Ormond Street. He was very talented and published widely and his well known book “A System of Radiology; with an Atlas of the Normal” came out in 1907.

The British radiological world was shocked when Bruce died of radiation-induced aplastic anaemia in 1921 at the young age of 42. The outcry resulting from his death resulted in the formation of a radiation protection committee.

George Harrison Orton was a pioneer of radiotherapy and was in charge of the X-ray department at St Mary’s Hospital in London. After his death it was said in his obituary that he was “perhaps the last martyr pioneer of radiology”. Stanley Melville worked at St George’s Hospital in London and was BIR president in 1934. Both Orton and Melville served periods as co-secretary with Sidney Russ (physicist at the Middlesex Hospital) of the newly formed British X-ray and Radium Protection Committee set up by the BIR, and radiation standards were set.

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About Dr Adrian Thomas

Dr Adrian Thomas

Dr Thomas was a medical student at University College, London. He was taught medical history by Edwin Clarke, Bill Bynum and Jonathan Miller. In the mid-1980s he was a founding member of what is now the British Society for the History of Radiology. In 1995 he organised the radiology history exhibition for the Röntgen Centenary Congress and edited his first book on radiology history.

He has published extensively on radiology history and has actively promoted radiology history throughout his career. He is currently the Chairman of the International Society for the History of Radiology.

Dr Thomas believes it is important that radiology is represented in the wider medical history community and to that end lectures on radiology history in the Diploma of the History of Medicine of the Society Apothecaries (DHMSA). He is the immediate past-president of the British Society for the History of Medicine, and the UK national representative to the International Society for the History of Medicine.

BRITISH INSTITUTE OF RADIOLOGY www.bir.org.uk

BRITISH SOCIETY OF HISTORY OF RADIOLOGY http://www.bshr.org.uk

 

The journey to a single RIS-PACS environment

JJ Alberts2  Main logo and main strapline

Dr Johann Albert, Associate Director, Business Solutions at Alliance Medical, discusses the challenge of varying client requirements in a private diagnostic imaging setting.

Unlike most NHS Acute Trusts, who tend to have large static diagnostic imaging departments located around a single or a small group of hospitals, private diagnostic imaging providers tend to have numerous static locations, a central patient management centre and varying fleet sizes of mobile scanners that move around on a daily basis. Private diagnostic imaging providers also have to contend with varying requirements from their customers that include scan-only services, book-scan-and-report services, or even report-only services. Service levels vary from customer to customer and the actual process of managing a patient differs between NHS, self-pay, medical insurance and medico-legal customers.

RIS PACS Icon logoThis variability highlights the fact that any clinical system deployed within a private diagnostic imaging provider needs to be able to cope with different workflows within the same location. It also implies that the clinical systems need to manage the end-to-end patient pathway in a manner that is completely separated from a fixed geographical location, as different parts of the patient pathway can take place in different locations. An example of this is where a patient calls the patient management centre to make a booking, the scan takes place at one of the scanning locations and the clinical report is completed by a tele-radiology provider. The clinical systems should therefore understand the concept of a workflow and a distributed network of scanning locations, as well as have the ability to move information seamlessly among various locations in accordance with the desired pathway.

The customer base of a private diagnostic imaging provider also varies from a commercial perspective. There are significant differences in customer requirements for management information, payment calculations and billing processes. This is on top of more intricate billing requirements such as factoring, zero-rated VAT or VAT exempt treatments that apply to some, but not all customers.

The realities of a business built up over time
Some of the private diagnostic imaging providers in the market started out in the pre-digital era and in the early days most diagnostic images were captured, stored and reported based on film. Over time RIS and PACS clinical applications appeared and of course private diagnostic imaging providers adopted these as appropriate. Since these technologies were still in their early phases of development, the designs tended to reflect the limitations in technology at the time and it was focussed on serving the needs of specific contracts. Some of these providers also grew by acquiring other smaller companies with their own legacy systems in situ.

These contributing factors typically result in a variety of RIS and PACS applications installed in the same organisation, all of which serve different purposes, different contracts and manage different parts of the patient pathway. To any manager the obvious implications of this scenario are, amongst others, large management overheads, a high degree of complexity in the technology solutions, various manual processes and an inability to rapidly change to accommodate customer needs.

Procuring a single RIS-PACS

To move from a situation where there are multiple RIS and PACS applications in place to a single unified system carries some significant challenges. Engrained manual business processes, distributed staff locations, radiologist availability and varying customer expectations are all significant challenges to overcome and manage. This is not even talking about the technical and logistical issues that a project of this nature would face.

Understanding the customers’ needs must form the core of any such change process and this must be layered on top of the requirements from the relevant operational teams. One of the key decision points in the design and deployment of a unified RIS-PACS environment is the balance that needs to be struck between flexibility and standardisation.

The flexibility within the system to accommodate operational needs and customer requirements is very important for any commercial organisation. On the other hand it is no use accommodating different customer requirements if these cannot be delivered to a consistent level of quality and to a consistent service level. Although there is a degree of overlap, these two system properties tend to be opposing forces in terms of the demands they place on a clinical systems platform. A good balance can only be achieved through proper engagement with customers and the relevant operational teams.

The procurement of a RIS and PACS system, at least from a private diagnostic imaging provider’s perspective, needs to fulfil several criteria and these include:

• It must have an integrated billing engine that can cope with all the requirements from different customers.
• It must manage the entire end-to-end patient pathway in the absence of a hospital information system (HIS), which includes multiple inbound channels and multiple outbound channels.
• It must allow for different workflows to be accommodated within the same clinical application that is a specific property of the contract associated with the patient.
• It must understand and cope with a distributed network of scanning facilities, some of which are static and some of which are mobile.
• It must allow for electronic interfaces and for the integration of any new developments to take place in a consistent way that is easy to manage.
• It must allow the private diagnostic imaging provider to change and configure the system as an inhouse function and not one that requires vendor intervention to the degree it is prevalent today.
• It must accommodate different clinical workflows that include scan only, scan and report, report only, double reads, report audits and also remote reporting.

This list is not meant to be comprehensive, but it is intended to highlight the requirements that a private diagnostic imaging provider will view as essential, as opposed to most radiology departments within a hospital setup. This set of criteria does point out the fact that most of the incumbent RIS vendors, and to a lessor extend the PACS vendors, do not meet all the criteria. It is therefore inevitable that some degree of customisation and development will be required for any clinical systems platform to be successful.

The implementation process
Once the appropriate systems have been procured, attention needs to turn to the implementation process. It goes without saying that a formal project methodology must be followed to have any hope of a successful implementation. Instead of providing an account of all the formal elements that a project of this nature requires, we would rather want to share our experience of the top four learning points:

Change: with any new system, there will be an element of change. The obvious example is the fact that staff members will be using a different clinical system to manage their daily workloads. There is however several areas of change that often get overlooked in a project of this nature. These include items such as the mechanism for how radiographers can move an image from the scanner to a specific radiologist. This is a simple task, but one which is core to the operation of any diagnostic imaging unit. The overall system might work very well, but if the key tasks that staff members need to perform on a daily basis are overlooked then it is easy to undermine the success of the entire project.

Process standardisation: implementing a single unified RIS and PACS implies that the same business process will be followed at each location. To assume that each scanning unit operates in exactly the same way will be a mistake though. Local business processes will have evolved over time and are a function of location-specific factors, customer-driven preferences, individual staff influences and of course head office standard operating procedures (SOPs). There must be a high degree of focus on ensuring business processes are standardised at each location, in order to accommodate a single RIS and PACS application. Deploying a system that enforces a standardised business process on a business environment that operates in a variety of ways, has the potential to stall the entire project.

Communication: with a workforce scattered around the country and a large proportion of it serving a mobile fleet, it is no surprise that communication is one of those tenacious challenges that needs constant attention. No single communication method will suffice in this situation and it is up the project team to use any and all means available to ensure the relevant messages reach the correct target audience. These methods can include anything from formal letters, face-to-face meetings and even social media. Social media is of course playing an increasingly important role in most people’s daily lives and it is a very useful tool in the business environment as well. External stakeholders need to be included at the appropriate times.

Coordination: the nature of most private diagnostic imaging providers is such that different parts of the patient work flow can take place at different locations. The payer of the service is mostly the determining factor that dictates which element needs to take place where. This is however a moving feat for the simple reason that patients from multiple contracts can be scanned at any scanning unit. The respective units therefore need to cope with different contract workflows at different times throughout the day. The implications for implementing a RIS and PACS as a unified platform is therefore that it is easy to undermine the company’s ability to service a patient if the implementation of all the different supporting systems are not well coordinated.

Conclusion
The latest technologies around work flow management will allow most private diagnostic imaging providers to improve productivity as well as quality at the same time, but it is important to realise that any project of this nature and scale requires just as much energy to manage the business change process as it requires to change the technical system. Even though the journey to a single RIS-PACS platform might have its challenges, it is our firm opinion that the benefits far outweigh the costs and the risks.

About Dr Johann Alberts

JJ AlbertsDr Alberts is a qualified medical doctor and his main clinical experience is in emergency medicine, both in the UK and South Africa. his experience includes private, public and military healthcare systems. In 2007 he made a career choice that deviated away from clinical medicine towards healthcare management. His passion is to design and implement healthcare services to ensure that more patients can benefit from what is already a scarce resource.

After completing an MBA at Oxford University, Johann joined BMI Healthcare as a Programme Director, where he managed four divisions that included Physiotherapy, Health Screening, Speech and Language Therapy and Occupational Health.

Johann joined Alliance Medical in 2012, first working at group level designing a quality strategy, implementing benchmarking and assisting on various projects around the company. At present Johann is directing the RIS-PACS implementation project, which will be completed in early in 2015.

Reflection, Surface and Material – What Lays ‘Beneath the Transparent’

HughTurvey_3_VLAs X-Pose Material and Surface Xogram exhibition opens in London, X-ray artist Hugh Turvey uses the exhibition themes to explore ways we can improve hospital environment through art.

Reflection
Four years ago I staged my first large public exhibition titled X-perimentalist. I rather fancied myself as a pioneer and wanted to reach out, to establish an audience who would appreciate the aesthetic of science and the emerging modality arts. I had come from a photographic background and wished to gain momentum for my work, as the earlier photographic pioneers had done before…a matter of classification, understanding and appreciation.

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So how did it turn out? Overwhelming, humbling and surprising …most notably an amazing relationship with the oldest radiological society in the world and a series of healthcare projects were born…I metaphorically became a dad again with a series of new challenges of language, communication and expectation to innovate a new visual concept of ‘transparency’ between practitioner and public. Modality art is the perfect medium that visually embodies the science and when presented artistically can elevate, educate and orientate.

Surface
Radiotherapy_UCH_HughTurvey_HiddenGarden_0012_Layer Comp 13The concept of revealing truth is one of the simplest structures in storytelling. Everyone loves a good story and the discovery of character hidden in sometimes the most unlikely places. When you read ‘cover to cover’ you physically move through the book absorbing matter on your journey. This absorption is compelling and second nature to us. You lose yourself in it.
But I find medical/healthcare environments not easy to read. The covers are not enticing, the pages are not printed correctly or in a language I do not understand and I can’t focus on the story line. I have orientation problems and am most happy when I put the book down.

As Professor Gary Royle, from University College London says “We should consider whether there are any innovative developments we can propose around patient experience, in particular for the paediatric patients. The hypothesis is that some studies have indicated that this can potentially have a positive effect on the patient mood / experience and so could be beneficial to the patients / treatments / staff.

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And here’s an idea of what could be done……

1. Explore the creative potential in the area between medical knowledge, understanding and use of modality art and the artists’ understanding of images and their power to communicate.
2. De-mystify the processes and technology used in diagnostic imaging to help engage patients, increase their understanding of the science and to help staff in communicating with them.
3. Produce artwork that is meaningful and engaging for patients, staff and visitors.
4. Develop a pilot/prototype educational tools which can help radiology staff in their work and benefit patients and the wider radiology community nationally.
5. Further artistic discourse and the debates surrounding art and science collaborations.
6. Aim to contribute to a re-engagement between the public and contemporary biomedical imaging techniques.
7. Implementation of new immersive way-finding, signage, feeds and curated digital art systems.

Transparent
Four years later, I know less having now seen the bigger picture.

Visit the exhibition at:
Xpose
gallery@oxo, Oxo Tower Wharf, Bargehouse Street, South Bank, London, SE1 9PH
Dates: 12 February – 23 February 2014
Opening Times: 11.00am – 6.00pm
Admission: Free

About Hugh Turvey’s Xogram work
High Turvey is an artist with an international reputation. His Xogram work is held in public and private collections throughout the world. Bridging the gap between art and science, graphic design and pure photography, it has been utilised in myriad applications, including, commercially, for marketing and advertising, in TV and film and by architects and interior designers.

Along with developing a body of work for the Science Photo Library, Hugh Turvey has collaborated on an ebook and iPad app called ‘X is for X-ray’ launched at the Radiological Society of North America (RSNA) in Chicago. His Xogram work has also been widely featured in newspaper articles and magazines around the world.

Among his commercial projects, he has made six award-winning TV adverts, using ground breaking Motion X-Ray. For the past three years he has been working with Waitrose UK on celebrity chef Heston Blumenthal’s ranges and has had images commissioned by L’Oreal, Paris.

Special thanks to: Senior Radiographer Sasha Moore YDH + Imaging Dept, Prof. Gary Royle UCL, Dr. Martin Fry UCL, Julia Solano + Radiotherapy Dept. UCLH, Niki Whitfield + Gloucestershire Oncology Centre Cheltenham and all the other hospital Trusts currently touring the Wellcome Trust inr-i project.