1	Finding Why the Radiology report not available: A Software Solution Amilcare Gentili, MD UCSD – San Diego VA HCS La Jolla, CA http://www.gentili.net http://www.bonepit.com
2	Introduction The installation and implementation of a hospital wide image management system has been reported to have a positive impact on radiology report turnaround time and has significantly reduced, but not eliminated the “lost film” and “missing report” problem.
3	Introduction To find the cause of “lost films” and “missing reports” in a filmless environment is important to follow each step of an imaging exam from the time a patient is schedule to the time a final report is signed. Comparison of the status changes in RIS (Radiology Information System) and PACS helps in identifying where a breakdown occurred and who is responsible to fix the problem (receptionist, technologist, PACS/RIS manager, transcriptionist, radiologist).
4	RIS Tracks 6 different status changes: Scheduled Complete (All images taken) Dictated Transcribed Final Cancelled
5	PACS Tracks 5 different status changes: New (N) Dictation started (d) Dictation completed (D) Transcribed (r) Final (R)
6	Radiology Workflow
7	Patient Checks-in at Radiology Front-desk Receptionist enter patient data in RIS RIS status changes to “Scheduled” Nothing happen in PACS
8	Exam is Cancelled If the wrong exam is scheduled or the patient refuses the exam the exam is cancelled. The RIS status changes to “Cancelled”. Nothing happen in PACS.
9	Technologist Takes Images and Send Images to PACS RIS status changes to “Complete” PACS status changes to “New”
10	Radiologist Starts Dictation RIS status remains “Complete” PACS status changes to “Dictation started”
11	Radiologist Completes Dictation RIS status changes to “Dictated” PACS status changes to “Dictated”
12	Report is Transcribed RIS status changes to “Transcribed” PACS status changes to: “reported”
13	Report is Signed by Attending Radiologist RIS status changes to “Final” PACS status changes to “Reported” Ideally all exams reach this stage
14	Status Changes
15	If the study does not reach the “Final” status Something went wrong during the process. To find out what went wrong: A report is generated from RIS with the list of studies older than 48 hours with a status different than “Final”. For each study in this report, the RIS status is compared with the PACS status.
16	RIS – PACS Status From the comparison of the RIS and PACS status is possible to determine, where a problem occurred and who is responsible to fix the problem. Although there are 42 possible combinations of statuses in RIS and PACS, problems can be grouped in 8 groups.
17	Missing Reports
18	"Manually comparing the status changes..." Manually comparing the status changes in RIS and PACS helps in identifying where a breakdown occurred and who is responsible to fix the problem, but is very time consuming. To expedite this process, we have developed an application that at scheduled intervals automatically compares the status changes in RIS and PACS and automatically generates reports of the problem cases. These reports are automatically printed on designated printers or emailed to the responsible parties.
19	How We Find Missing Cases
20	Automatic Comparison
21	RIS Status: Transcribed PACS Status: reported Problem: The report is not signed. Solution: The radiologist need to sign the report.
22	RIS Status: Complete PACS Status: New Problem: The radiologist did not dictate a report or the radiologist did not receive the images. Solution: Radiologist need to dictate a report. PACS administrator need to make sure that the study is sent to the appropriate radiologist.
23	RIS Status: Complete PACS Status: Dictation started or Dictated Problem Dictation is not transcribed or the dictation is missing. Solution If dictation is available: Transcriptionist need to type the report. If dictation is unavailable (status toggled to “dictated” by mistake or dictation is lost). -PACS administrator need to change status in PACS back to “New”. -Radiologist need to dictate a report.
24	RIS Status: Complete PACS Status: Reported or Final Problem: Status toggled by mistake in PACS or report entered by mistake in RIS and removed from RIS but status not updated in PACS. Solution: PACS administrator need to change status in PACS back to “New”. Radiologist need to dictate a report.
25	RIS Status: Complete PACS Status: Dictation started or Dictated If dictation is available Transcriptionist need to type the report. If dictation is unavailable (status toggled to “dictated” by mistake) PACS administrator need to change status in PACS back to “New”. Radiologist need to dictate a report.
26	RIS Status: Complete PACS Status: No images Problem: There are no images for a study. Solution If the study was performed Technologist needs to send images to PACS. If the study was not performed Technologist needs to cancel study in RIS.
27	RIS Status: Scheduled PACS Status: No images Problem: A study remains in scheduled status. Solution: If the study was performed Technologist needs to toggle the study to complete in RIS and send the images to PACS. If the study was not performed Technologist or receptionist needs to cancel study in RIS.
28	RIS Status: Cancelled PACS Status: New, Dictated Problem: Images are in PACS for a study that is cancelled in RIS. Either the study was cancelled by mistake after the images were obtained or the images are associated to the wrong study. Solution: If the study was cancelled by mistake after the images are obtained the technologist needs to enter a new study in RIS and associate the images in PACS to the new study. If the images were associated to the wrong study, the technologist or PACS administrator need to associate the images in PACS to the correct study.
29	RIS Status: Nothing PACS Status: New, Dictated Problem: There are images in PACS that do not correspond to any study in RIS. Often these images do not belong to patients but are of phantoms or research subjects. Solution If the study was performed on a real patient, receptionist/technologist needs to enter a study in RIS.
30	Software Solution Every day at 6 am information on exams performed in the past 2 weeks are extracted from both RIS and PACS using capability built in RIS (Idxrad) and PACS (Agfa). The data are saved as text files and transferred to a designated server.
31	Software Solution Using Visual Basic for Applications the text file created by RIS and PACS are automatically imported into a Microsoft Access database.
32	Database Structure Main tables RIS PACS Supporting tables Procedure codes Source calling titles
33	Tables
34	PACS Data Table Contains data extracted from PACS
35	RIS Data Table Contains data extracted from RIS
36	List of Possible Studies in RIS Contains list of procedure that can be order in RIS, the locations where the exams are done and by which section the images are interpreted
37	PACS Source Calling Titles It is used to determine the location where images were taken.
38	Multiple reports are automatically generated transcribed reports requiring signature sorted by radiologist studies with images but no report sorted by radiology section and location studies with wrong status in PACS study without images sorted by the technologist who performed the study studies with images in PACS and no accession in RIS sorted by modality and location.
39	For the Radiologist – Missing Dictations
40	For the RIS/PACS Administrator – Images without an Order Number
41	For the RIS/PACS Administrator –Orders without Images
42	For the RIS/PACS Administrator Discrepancy between PACS and RIS Statuses
43	Worklist Generation Worklists of studies that need dictations are also automatically generated. Worklists can be emailed, as they contain only the study unique identifier and no protected patient information. The reports are not emailed as they contain patient names.
44	Conclusion When trying to solve the "lost film” and ”missing report" problem, comparison of the status changes in RIS and PACS helps in identifying where a breakdown occurred and who is responsible to fix the problem.
45	Conclusion Comparing the status changes in RIS and PACS is very time consuming, if done manually. Using a database application that at scheduled intervals automatically compares the status changes in RIS and PACS and automatically generates reports of the problem cases, reduces significantly the time spent for fixing problem cases.
46	References Hayt DB, Alexander S. The pros and cons of implementing PACS and speech recognition systems. J Digit Imaging. 2001 Sep;14(3):149-57. Hayt DB, Alexander S, Drakakis J, Berdebes N. Filmless in 60 days: the impact of picture archiving and communications systems within a large urban hospital. J Digit Imaging. 2001 Jun;14(2):62-71. Mehta A, Dreyer K, Boland G, Frank M. Do picture archiving and communication systems improve report turnaround times? J Digit Imaging. 2000 May;13(2 Suppl 1):105-7.