Background

If patient care is a workflow combining human and technical systems then Radiology has seen two generational changes in the past 5 years. 5 years ago, workflow was structured around paper Requisitions and Film Folders. Workflow was completely controlled by people. Front office clerks, technologists, film librarians and medical secretaries would key, print, sort, label, file, hang and pull, paper and film folders to control the workflow. Physicians could monitor the process simply by looking at the stack of requisitions in their inbox or the stack of film folders next to the lightbox. Human error would typically result in lost or mislabeled films but the human systems had evolved to deal with these errors and other exceptions.

Then the first generation of integrated computerized medical records came along. ADT, RIS and EMR computers started to interface with each other and with PACS. This is the age of HL7, Modality Worklist and IHE. It was an opportunity for software and IT vendors to sell wondrous (n.b.: my spell checker proposed ponderous here) new systems and to charge lots of money to customize and reengineer the old-fashioned workflow managed by old-fashioned intelligent beings. Unfortunately, a simple mouseclick error or routine technical problems that could be easily spotted by humans before are now magnified by the mechanistic "fire-and-forget" approach of enthusiastic integrated systems.

Physician adoption of these integrated novelties has been spotty. Security and problems with multiple sign-on requirements led to the invention of CCOW as a human-oriented patch to HL7. Unfortunately, both HL7 and CCOW (which is now a part of HL7) are "consensus" standards meant to protect the interests of the incumbent software vendors at the expense of physician users. Physicians just want single sign-on with the ability to use their image viewer and dictation system as an integrated pair and with the flexibility to adapt to the dynamic demands of real-world clinical practice.

For the most part, neither referring physicians nor radiologists want a RIS or workflow of any kind. The referring physician wants order status and images to be linked directly to the patient's EMR and the radiologist would be happy with a Next button on their viewer that is backed up by a "whiteboard" that passively displayed how much of what kind of work remained to be done.

The RealTime Worklist Approach

Real-Time Worklist is a new approach to this problem that re-introduces the flexibility for humans to respond to the demands of everyday life and reduces the cascade of errors common in today's "integrated" systems.

Our approach is made possible by new real-time messaging technology way beyond HL7 queues and ponderous server-oriented middleware. The positive benefits HL7, CCOW and IHE are preserved as technologies that avoid redundant keystrokes for technicians and physicians alike. In its simplest form, RealTime Worklist is analogous to the giant list of trains at a railroad station. It is always up-to-date (real-time), public and people in multiple roles often use the same list. RealTime Worklist is much more user friendly than RIS-driven lists and our early experience shows that its real-time, public and shared architecture significantly reduces the impact of both human errors and technology bugs. Furthermore, RealTime Worklist improves service to the patients and referring physicians by organizing the intelligent response of technical staff and physicians in response to real-world demands.

Key Elements of the RealTime Worklist

• Shared Scope
  A public worklist must serve multiple user roles. Patients with Pending, In-process and Complete workflow status are simultaneously on display to give all users the opportunity to react to unusual situations. A consistent column arrangement in the user interface makes it easy for users to work with different worklists as they move from ER to Clinic to Reading Room. Automated Hide / Show algorithms are supplemented by simple manual overrides to allow users a "personal" copy of a public worklist.
• Passive Design
  When things are working as planned, most users never have to click on a worklist. Automatic scoping avoids scroll bars. This feature is essential to worklist sharing.
• Real-Time Status Display
  All status changes are instantly reflected in all worklists. This eliminates the need for confusing popup windows. Image counts change dynamically to display progress.
• Easy Change of Workflow Status
  Any authorized user can react to demands by changing a Web form or directly from any Vision workstation. Authorization is integrated with the Vision security system.
• Coloring by Workflow Status
  Status coloring makes even the busiest operation easier to understand.
• Highlighting of Errors and Exceptions
  STATs, system errors and human warnings are separate from workflow for emphasis.
• Actionable Icons
  One-click Action Icons highlight to reinforce workflow status and deliver a true "single-sign-on" experience.
• Web Accessibility
  Like instant messaging, RealTime Worklist are as handy as your browser or Web phone.
• Effective Logs and Management Reports
  Worklists and Action Icons are complemented by consistent administrative reports.
• Tight Integration with both Vision Workstations and Third-Party Software
  Dictation, 3D Workstations, CPOE, RIS and enterprise security are supported.
• Independent of RIS and EMR
  RealTime Worklist can be deployed either before or after a RIS or EMR.
• Configurable for Each Institution
  Workflow states, user roles, labels and identifiers are fully configurable for the way things actually work and help to keep simple things simple.

Conclusion

Power to the People!