A Radiology Dashboard as a Tool to Improve the Turnaround Time of Dictated ReportsAlexander J. Towbin MD, Seth Hall, Jay Moskovitz MS, Laurie Perry RN, Neil Johnson MD, Lane F. Donnelly MD

Introduction to the Problem:

Materials and Methods:

lOneofthehopesofdigitalimagingwasthattheproblemofstudiesbeinglostandsubsequentlynotdictatedwoulddisappear

lWhilethenumberofundictatedstudieshasdecreased,theproblemstillexiststCauseoftheproblemhaschangedn Film-basedera:undictatedstudiesinthepossessionoftheorderingclinicianorlostinthefileroomn Digitalera:technologisterrorandradiologisterror

lTechnologisterrortDifferentateachhospitalanddependentontheinformationsystemsandfail-safemethodsemployedtopreventerrors

tTypesoftechnologisterroratourinstitutionn Studynotcompletedintheradiologyinformationsystem(RIS)n Studynotenteredintodepartmentalworkflowmanagementsystem,RadStream

lRadiologisterrortFailureofaradiologisttodictateastudyontheirindividualworklistn Potentialtocausedelayindiagnosisn Studydoesnotappearonotherradiologists’worklistsn Unlessanotherradiologistisnotified,thestudyremainsunread

tFailuretolinkastudyn Doesnotaffectpatientcarebutdoesaffectbillingn Dictatedreportisavailabletocliniciansbutisnotassociatedwithallindividualcomponentsof

thestudy

lHypothesistAdashboardwilldecreasetheturnaroundtimeforradiologyreports

lAradiologydashboardwascreatedtDashboardobtainsdatafromRISandRadStreamtProvidesagraphicalrepresentationforeachmodality(Fig.1)n Numberofstat-casestobereadn Numberofnon-statcasestobereadn Numberofcaseswherethetimesinceend-examis>24hours

tHighlightsstudiescompletedinRISbutthathavenotbeenenteredintoRadStreamformorethan30minutes(Fig.2)

lRetrospectivestudytEvaluatetheutilityofthedashboardindecreasingtheaveragetimebetweentheend-examstepandstudycompletion(dictatedandsignedbythestaffradiologist)

lAllstudiesevaluatedandreportedusingthesameinformationsystemstRIS(GECentricityRISv1.0;GE,Milwaukee,WI)tPACS(GECentricityv2.1;GE,Milwaukee,WI)tSpeechrecognitionsoftware(PowerScribeSDKembeddedforGECentricity;Nuance,Boston,MA)

lOutcomesevaluatedtTotalnumberofstudiesdictatedtAveragetimefromendexamtothefinalizedstatustAveragenumberofstudiespermonthwithaturnaroundtime>24hours

lThreeseparatestudyperiodstBetweenJanuary1,2006,andDecember31,2006,beforethedashboardwasimplementedtBetweenSeptember1,2007,andAugust31,2008,immediatelyafterthedashboardwasimplementedtBetweenSeptember1,2008,andJune1,2009,afterapolicywasimplementedwheretechnologistmanagersactivelymonitoredthedashboardforproblemcasesn Problemcasedefinitionn Studynotbeendictatedfor>24hoursn StudycompletedinRISbutnotenteredintoRadStream

lBetweenJanuary1,2006,andDecember31,2006tBeforethedashboardwasimplementedn 204,022studiesreadn 32radiologistsn 523minutes(8.7hours)betweenendexamandafinalizedreportn 696studiespermonthwithturnaroundtime>24hours

lBetweenSeptember1,2007,andAugust31,2008tImmediatelyafterthedashboardwasimplementedn 217,965studiesreadn 34radiologistsn 426minutes(7.1hours)betweenendexamandafinalizedreportn 527studiespermonthwithturnaroundtime>24hours

lBetweenSeptember1,2008,andJune1,2009tAftertheimplementationofthepolicyfortechnologistmanagerstocheckthedashboardactivelyforproblemcasesn 159,652casesreadn 35radiologistsn 237minutes(3.9hours)betweenendexamandafinalizedreportn 467studiespermonthwithturnaroundtime>24hours

lThenumberofstudiesreadpermonthperradiologistcomparedtotheaverageturnaroundtimeisshowninFigure3

lAveragenumberofstudiesreadpermonthcomparedtotheaveragenumberofstudiespermonthwithaturnaroundtime>24hoursisshowninFigure4

lTurnaroundtimeforreportsdecreasednearly55%overthestudyperiod.tNootherimprovementsonworkflowefficiencywereimplemented

lImprovementcanbeattributedtothreemajorfactorstIncreasedawarenessofadelayedturnaroundtimetDecreaseinthenumberofoutstandingproblemcasestIncreasedfocusofdepartmentalleadershiptoimprovetheturnaroundtime

lMethodsbywhichthedashboardimproveddepartmentalawarenesstContinuousdisplayinthemainreadingroominourdepartment(Fig.5).n Centrallocationn Visibletoeveryonepassingthroughthedepartmentn Providesup-to-the-minutesnapshotofoutstandingwork

tAccessiblethroughthehospitalintranettAllowsreadingroomassistantstogaugethestatusofthedepartmentn Ifaradiologistisbehindby>40studies,thereadingroomassistantpagesallradiologiststohelp

readstudies

lDecreaseinproblemcasessignificantlydecreasedturnaroundtimetLargestimprovementinturnaroundtimeoccurredafterthetechnologistmanagersbeganactivelymonitoringthedashboard

tDashboardwasdesignedtoidentifythemainsourcesofundictatedstudiesn Technologisterror(Fig.2)v CasesnotenteredintoRadStreamidentifiedbyalargerednumbernexttothemodalityv Technologistmanageridentifiestheoffendingstudybyclickingthenumberonthedashboardn Radiologisterror(Fig.6)v Studiesundictatedfor>24hoursv Investigatedbyclickingtheyellowbaronthedashboardv Technologistcontactsradiologisttoreaddelinquentstudy

lIncreasedattentionfromdepartmentalleaderstThedashboardhelpedtoidentifytheproblemandincreaseawarenessn Centrallocationofdashboardv Highlightedproblemofunreadstudiesv Madeproblemahighpriorityinthedepartmentn Continuedpolicychangesbasedonproblemsidentifiedbythedashboardv Institutedpolicyfortechnologistmanagerstocheckthedashboardactivelyforproblemcasesv Institutedpolicyforreadingroomassistantstopageallradiologistsifthenumberofunread

studieswas>40

lImprovementinturnaroundtimesrelatedtothedashboardrivalgainsseenwithimplementationofPACSandspeechrecognitionsystems[1–5]

lOneotherreportofimprovedturnaroundtimethroughimplementationofadashboard[6]tDashboarddifferedinseveralrespectsn Metricsmeasuredv Ourdashboardm Numberofunreadstudiesindifferentcategoriesm Numberofstudiesnotavailabletoreadm Patientswaitingfortheirimagingstudies

v Previouslyreporteddashboardm Individualnotificationsm Divisionalnotificationsm System-widenotifications

v Differencesattributedtosizeandneedsoftwodepartmentsv Foradashboardtobesuccessful,eachdepartmentmustdeterminethebottleneckstepsthat

slowturnaroundtimesn Causeofimprovedturnaroundtimev Ourdashboardm Identificationofproblemstudies

v Previouslyreporteddashboardm Notificationofnumberofreportsreadytobesigned

v Highlightsimportanceofeachindividualdepartmentidentifyingbottleneckstepsn Locationofdashboardv Ourdashboardm Internetbasedm Largemonitorinacentrallocation

v Previouslydescribeddashboardm IntegratedintoPACSm Visibletoeachradiologistwhileworking

v IntegrateddashboardisidealbutnotpossiblewithmostPACStCommonalitybetweenthetwodashboardsn Increasedawarenessofaproblemv Providesasnapshotofthesystemandidentifiesbottlenecksn Increasedawarenessofmonitoringbydepartmentalleadership

lLimitationsofourstudytRetrospectivenaturen Hardtoensurethatallgainsweretrulyaresultofthedashboardv Possiblethatotherpolicychangesaffectedturnaroundtimev Noothersystemsinstalledtoimproveworkflowefficiency

tDoesnottakeintoaccountthechangeinstaffingoverthestudyperiodn Possiblechangeinreadingratesofdifferentradiologistsn Overallincreaseinradiologistsoverstudyperiodn Notthoughttobemainsourceofimprovedturnaroundtimev Increasednumberofradiologistswasusedtofreeradiologistsformoreresearchtimev Day-to-dayschedulewasnotsignificantlyaffectedv Averagenumberofstudiesreadperradiologistpermonthdidnotchangesignificantly(Fig.3)v Duringthetimewhenthelargestgainswerenotedonlyoneadditionalstaffmemberwasadded

lLargestgainswereattributedtopolicyrequiringtechnologistmanagerstoactivelymonitorthedashboardforproblemcasestCombinationoftechnologyandhumaninterventionisoftenneededtoworkinconcerttoaffectthelargestchange

lDashboardwassuccessfulindecreasingtheturnaroundtimeforradiologyreports

lCausesofimprovementsinturnaroundtImplementationofdashboardtImplementationofapolicywheretechnologistmanagersactivelyidentifyproblemcasesonthedashboard

tIncreasedawarenessofaproblem

1. HaytDB,AlexanderS.TheprosandconsofimplementingPACSandspeechrecognitionsystems.JDigitImaging.2001;14:149-157.

2. MatternCW,KingBFJr,HangiandreouNJ,etal.Electronicimagingimpactonimageandreportturnaroundtimes.JDigitImaging.1999;12(Suppl1):155-159.

3. BolandGW,GuimaraesAS,MuellerPR.Radiologyreportturnaround:expectationsandsolutions.EurRadiol.2008;18:1326-1328.Epub2008Mar8.

4. NitrosiA,BorasiG,NicoliF,etal.Afilmlessradiologydepartmentinafulldigitalregionalhospital:quantitativeevaluationoftheincreasedqualityandefficiency.JDigitImaging.2007;20:140-148.Epub2007Feb23.

5. LepantoL,ParéG,AubryD,etal.ImpactofPACSondictationturnaroundtimeandproductivity.JDigitImaging.2006;19:92-97.

6. MorganMB,BranstetterBF4th,LionettiDM,etal.Theradiologydigitaldashboard:effectsonreportturnaroundtime.JDigitImaging.2008;21:50-58.Epub2007Mar3.

© 2009 Cincinnati Children’s Hospital Medical Center, Radiology Department, Digital Imaging Lab, Glenn Miñano

Results:

Discussion:

Conclusion:

References

Figure 3

Page 1

0

100

200

300

400

500

600

2006 2007/2008 2008/2009

Year

Nu

mb

er o

f st

ud

ies

read

per

rad

iolo

gis

t p

er m

on

th

0

100

200

300

400

500

600

Tim

e in

min

ute

s b

etw

een

en

d e

xam

an

d a

dic

tate

d f

inal

ized

re

po

rt

Number of studies readper month perradiologist

Average number ofminutes between endexam and a finalizedreport

Figure 3

Page 1

0

100

200

300

400

500

600

2006 2007/2008 2008/2009

Year

Nu

mb

er o

f st

ud

ies

read

per

rad

iolo

gis

t p

er m

on

th

0

100

200

300

400

500

600

Tim

e in

min

ute

s b

etw

een

en

d e

xam

an

d a

dic

tate

d f

inal

ized

re

po

rt

Number of studies readper month perradiologist

Average number ofminutes between endexam and a finalizedreport

Figure 4

Page 1

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

20000

2006 2007/2008 2008/2009

Study Period

Ave

rag

e N

um

ber

of

Stu

die

s R

ead

per

Mo

nth

0

100

200

300

400

500

600

700

800

Ave

rag

e N

um

ber

of

Stu

die

s p

er M

on

th w

ith

a T

urn

aro

un

d T

ime

> 2

4 h

ou

rs Average number of studies per month

Average number of studies per monthwith a turnaround time greater than 24hours

Figure 4

Page 1

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

20000

2006 2007/2008 2008/2009

Study Period

Ave

rag

e N

um

ber

of

Stu

die

s R

ead

per

Mo

nth

0

100

200

300

400

500

600

700

800

Ave

rag

e N

um

ber

of

Stu

die

s p

er M

on

th w

ith

a T

urn

aro

un

d T

ime

> 2

4 h

ou

rs Average number of studies per month

Average number of studies per monthwith a turnaround time greater than 24hours

Figure 1. Screen capture of the dashboard used in our department. The dashboard displays three key pieces of information. The largest and most visible information is the graph at the top of the image. This graph gives a snapshot of the outstanding work within the department. The outstanding studies are first separated by modality (CT, interventional, MRI, orthopedics clinic, radiography, ultrasound, and teleradiology). Within each modality, the number of outstanding studies is further broken down into stat cases (red), cases outstanding for over 24 hours (yellow), and non-stat cases (blue). On the bottom right side of the dashboard, the number of studies completed in the radiology information system but not entered on the radiologist’s worklist is highlighted, again broken down by modality. Finally, on the bottom left side of the dashboard is an area for technologists to identify the patients who are currently checked in and waiting for their study to be performed. There is a drop-down field for each modality to identify individual patients. This last portion of the dashboard was not assessed in this study.

Figure 2. In the bottom right corner of the dashboard, the number of studies completed in the radiology information system but not entered into the radiologist’s worklist are highlighted. If the user clicks on the red number, he or she is able to see the accession number of the offending study. This allows the technologist to correctly enter the study onto the worklist.

Figure 3. Graph showing the average number of studies read per radiologist per month over the study period (purple bars) compared to the average number of minutes between the end-exam step and a finalized report (blue line). While the average number of studies read per month per radiologist stayed relatively stable, the turnaround time dropped by more than 50%.

Figure 3. Graph showing the average number of studies per month over the study period (purple bars) compared to the average number of studies per month with a turnaround time greater than 24 hours (blue line). While the average number of studies read per month increased slightly the number of studies per month with a turnaround time over 24 hours decreased.

Figure 5. Photograph showing the central location of the main dashboard within the central reading room in the department. This central location allows radiologists, technologists, reading room assistants, and administrators to obtain an up-to-the-minute snapshot of activity in the department.

Figure 6. Studies that have not been dictated in over 24 hours (yellow bars on the dashboard) can be investigated as to the source of the delayed dictation. The technologist clicks on the yellow bar and the offending cases and their information are displayed (shown in the lower half of the figure).