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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5784_Библиотеки_им_академика_М_И_Перельмана.pdf
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Workflow Diagram
Remote
Worklist Modality
Barcode Entry
C.J. Bryczkowski and M.W. Byrne
DICOM
PACS
Report
Generation
EMR
DICOM
Middleware
Billing
HL7
ADT
Credentialing
Image
Review
CPOE
Quality
Assurance
Access
Fig. 17.1 Workow overview diagram
Data Entry
Upon initiating an ultrasound exam, various demographic information needs to be
entered into the ultrasound machine in order to link the study to the patient’s hospital record. This usually consists of the patient’s name and medical record number
and may also include additional information such as the date of birth. Likewise, the
provider performing the scan has to input his or her name. Manual entry of this data
is both tedious and more importantly prone to human error. Automated solutions
exist to streamline this workow process.
The admissions, discharge, and transfer (ADT) system serves as the framework for most hospital IT systems. It holds essential patient information including full name, date of birth, and medical record and account numbers. When
patients enter a healthcare facility, their registration information is linked to and
stored within the ADT.The ADT system is then utilized for patient tracking and
throughput as well as billing purposes. The ADT shares relevant patient data
(such as demographics or isolation precautions) with other hospital IT systems
such as the EMR [4].
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285
One function of DICOM protocols is a modality worklist, whereby ultrasound orders submitted into computerized physician order entry (CPOE) are
transferred to the ultrasound machine in a worklist format. When beginning a
scan on a patient, the corresponding order within the modality worklist on the
ultrasound machine may be selected, which then autopopulates multiple
demographic fields using information from the ADT system. While this process is native to any ultrasound machine with DICOM functionality, middleware products can be utilized to facilitate modality worklist generation. Using
information from the ADT system, middleware can create a worklist of all
patients currently residing within the ER, bypassing the need to place an initial CPOE order.
Another means of autopopulating patient information onto the ultrasound
machine is via barcode scanners. Healthcare institutions encode patient information onto barcodes residing on patient identication bracelets. Most ultrasound vendors support barcode scanners that can then be used to transmit
information from the patient barcode into elds on the ultrasound machine.
Often these barcode scanners are proprietary and specic to the individual ultrasound machine vendor, although on certain machines a standard barcode scanner (e.g., Motorola Symbol series) can be attached to the machine’s USB port.
It is important to recognize that the information that the patient barcode encodes
for varies across different institutions. While often the barcode contains the
medical record number, it may also encode for different patient data, such as the
visit number.
Report Generation
Middleware user interfaces are designed to allow for a high degree of customization. Categorizing studies by patient, the performing provider, date of scan, or the
machine used should all be easily congurable options (Fig.17.2).
After an ultrasound study is complete, images and scan data can be sent via
DICOM to middleware. Interpretation of the ultrasound exam can then be
entered into an electronic worksheet on a computer workstation. Interpretation
worksheets should be fully customizable by the administrator in order to tailor
to the needs of the individual hospital site (Fig.17.3). In certain circumstances,
depending on the specic middleware product and ultrasound machine vendor,
worksheets can be completed directly on the ultrasound machine. This streamlined approach of performing and interpreting ultrasound studies at the point
of care has been a frequently requested feature for many users of clinical
ultrasound.
286
C.J. Bryczkowski and M.W. Byrne
Fig. 17.2 Sample middleware worklist. © 2016 BK Ultrasound
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287
Fig. 17.3 Sample exam report. © 2016 Telexy Healthcare Inc
288
C.J. Bryczkowski and M.W. Byrne
Image Review/Quality Improvement
As a clinical ultrasound program grows, it is imperative to have a structured
approach to image review. An ever-increasing number of images to review may
consume large portions of the ultrasound site director’s time and efforts. As discussed above, middleware products allow for high degrees of customization in organizing scans within the ultrasound exam database. For example, scans can be
reviewed by a given day or range of dates, performing provider, or ultrasound
machine used. Both image review and quality assurance templates can be viewed
simultaneously for each specic ultrasound exam type and thus signicantly cut
down the amount of time it takes to assess a scan (Fig.17.4).
Middleware software also incorporate image and video playback tools to facilitate image review. For example, brightness and contrast can be adjusted, images can
be zoomed into and enlarged, and videos can be viewed frame by frame to allow for
precise analysis (Fig.17.5). Feedback can be relayed not only in the form of written
text but also by annotating images and videos. Via an automated process, the software can then compile feedback into a report that is sent to the clinician who performed the study (Fig.17.6).
Education/Credentialing
Timely feedback is particularly important when trainees are involved. Some ultrasound clips may contain common ndings, while others subtleties. In both instances,
valid teaching points regarding scan technique, image interpretation, or medical
management may be important to make. Accordingly, middleware software provides a means for image and video exportation into commonly used le formats.
Automated removal of patient identiers from ultrasound scan images avoids potential violation of the Health Insurance Portability and Accountability Act (HIPAA).
Exported images and video clips can subsequently be used in publications or presentations to share with the broader medical community.
As providers submit increasing numbers of scans, it is important to track individual
provider scan numbers. Resident scan numbers must be followed in order to ensure they
meet ultrasound milestones, and attending physician scan numbers must be tracked for
hospital credentialing purposes. All ultrasound scans already reside within the middleware exam database, and middleware software provides functionality to easily generate
reports of number of scans performed by each individual provider (Fig.17.7).
Furthermore, data obtained from worksheets can be used as a part of a robust
research database. Interpretation worksheets may be rened to identify specic data
points (for example, ultrasound-guided peripheral intravenous access placed in
transverse approach), which can be an invaluable aid when planning and performing
research projects. Data can then be easily exported and compiled to standard spread-
®
sheet software (Microsoft Excel
) for further analysis.
17 Workow andMiddleware
289
Fig. 17.4 Sample quality assurance worksheet. © 2016 Telexy Healthcare Inc
290
C.J. Bryczkowski and M.W. Byrne
Fig. 17.5 Sample image viewer. © 2016 UltraLinq Healthcare Solutions Inc
17 Workow andMiddleware
Fig. 17.6 Sample exam report. © 2016 BK Ultrasound
291
Fig. 17.7 Sample statistics report. © 2016 Telexy Healthcare Inc
292
C.J. Bryczkowski and M.W. Byrne
Order Entry/Billing
The method of billing for clinical ultrasound exams varies greatly across different
institutions. In some instances, the billing interface may be built directly into the
EMR, while in others it may be independent. In either case, the use of middleware
to facilitate ultrasound billing can capture substantial revenue, which may rapidly
pay for the cost required for initial software implementation.
Analogous to ultrasound machines communicating with middleware via DICOM,
middleware has the capability to interact with EMRs using what is known as Health
Level 7 (HL7). HL7 refers to a set of standards used in the transfer of administrative
and clinical data among various healthcare software applications. It serves to enhance
interoperability, giving electronic systems the ability to exchange information [5].
Any bill generated from an ultrasound exam has to rst start with a request, or an
order to perform the study in the rst place. Via the use of HL7 connectivity, the request
for the completion of the ultrasound exam can be accomplished in various ways.
The order to perform a clinical ultrasound exam can be placed using the CPOE
functionality of an EMR.Middleware software can be congured to receive this
request and send the ordered study to a modality worklist on the ultrasound machine.
The provider can then select the corresponding study from the modality worklist on
the ultrasound machine as previously discussed. After images have been obtained
and a study interpretation has been entered, the middleware software will then automatically generate a billing report.
Through the use of middleware, this task can also be accomplished retrospectively. For instance, if a patient presents in extremis, an ultrasound is often performed
at the point of care without any known demographics. Once the ultrasound examination is complete, the appropriate MR (Medical Record) number can be placed within
the middleware and then all other relevant elds including name, age, and account
number will autopopulate. A report worksheet can then be lled out and subsequently
submitted for billing. In this scenario, middleware can automatically communicate
with the EMR and place an order for the completed ultrasound exam on the backend. As a result, when a bill is generated it is directly tied to a request for it.
In either scenario, the middleware can also facilitate billing inquiries. It can check
whether appropriate sections of a report were lled out in order to generate a bill. Likewise,
it can be set to ag studies that, for instance, don’t have indications or appropriate charge
codes selected. This can aid an administrator in understanding why certain examinations
were not successfully billed and in some cases perform a simple x in order to resubmit.
Middleware Vendors
Given the distinct advantages that they offer, the market for middleware management systems is blossoming. At the time of this writing, there are three major vendors that offer workow systems: Q-path™ (Telexy Healthcare), BkHub™ (BK
ultrasound), and UltraLinq
®
. Additionally, there are many upcoming software
17 Workow andMiddleware
293
companies such as Tricefy™ (Trice Imaging, Inc.), which will further add diversity
to a growing market segment. Until recently, SonoSite™ (Fujilm Inc.) ultrasound
systems had made their own workow solutions software “SonoSite SWS” but have
since advertised support to the use of Q-path. At the time of this writing, Q-path
seems to have the largest point of care market share [6].
All middleware workow solutions have the overall goal of facilitating the user
in the archive, review, and dissemination of clinical ultrasound examinations.
Nevertheless, there are distinct differences among them, which must be assessed in
detail prior to a purchasing decision. While comparing and contrasting each individual feature is beyond the scope of this chapter, some key differences, current at
the time of this writing, will be reviewed.
Q-path and BkHub are installed on local servers within a medical institution
(Figs.17.8 and 17.9) They can both send images to PACS, but may also work independent of one for clinical ultrasound exams. Both are HL7 compatible and are
interlinked to other hospital data systems via the hospital network.They have a
robust interface for reviewing examinations and allow the administrator to customize worksheets for both report generation as well as quality assurance/feedback.
They both support integrated worksheets, but this depends on the ultrasound
machine vendor. For instance, BkHub supports worksheets only on Bk ultrasound
systems. Remote access is achievable with both Q-path and BkHub through the use
of a point-to- point connection. Depending on the healthcare institution this may be
via the use of a hospital-based virtual private network (VPN) or a commercially
™
available solution such as Citrix
(Citrix Systems, Inc.). In essence, a user connects
to the middleware for remote viewing by having to rst connect to the hospital network and accessing the software through it.
UltraLinq as well as Tricefy are cloud-based storage systems in which examinations are hosted on a server external to the medical institution. Much like any other
website, they offer the advantage of easy access from any Internet enabled device—
there is no need for connecting to the hospital network. However, as the workows
are web-based, UltraLinq and Tricefy both do not offer support for integrated worksheets on ultrasound systems. Furthermore, there is no ability to send images from
the worklist directly to a PACS, if needed. They do offer feedback reporting, but do
not offer the customizable worksheets to the degree that the locally stored middleware allow (Figs.17.10 and 17.11).
Of note, Q-path also has a cloud-based storage option “Q-path Cloud” which
offers the dual benet of having a locally installed server, along with off-site storage
hosted by Q-path. This hybrid model may be benecial to share image data for those
within a healthcare system that has more than one site.
Generally, middleware that is locally hosted, such as BkHub and Q-path, have a
much higher upfront cost versus web-based workow platforms. This cost can
range in the ballpark of $10,000 to $20,000+. Web-based solutions, such as
UltraLinq or Tricefy, are typically based on a at fee per scan cost model. Deciding
on a middleware platform is much like expanding an emergency department—one
has to anticipate growth. If clinical ultrasound studies are only going to be performed by credentialed providers and billed, then paying a small cost is cheaper and