Getting the Images to the Emergency Room

Normally, attention is focused on workflows that provide the emergency department (ED) physicians with images and radiology reports in a timely fashion. There are a number of discrete workflows (including communications) that address the interplay of patient, radiology and the ED staff. This can usually be handled by fairly straightforward means using the available technologies.

Things get more complicated when an outlying emergency room needs to transfer the patient to a trauma center. Whether an ambulance or helicopter is used, it will usually take valuable time to get the patient to the new location, very often along with a CD/DVD or hardcopy films of radiology images that were taken in the initial ER. More time is then spent in re-evaluating the images and the patient.

If we leverage the Internet to securely transmit such images before the patient arrives at the trauma center, then surgeons and radiologist can evaluate, plan and prepare treatment ahead of the patient’s arrival. At Hennepin County Medical Center (HCMC), I set up VPN connections with a few of the top referring ERs. This allowed these facilities to send diagnostic quality Dicom images directly to HCMC where radiology, the ER, and the surgeons could review them. Since its inception, this service has been expanded to half a dozen referring facilities.

New Mexico has a system called IMEDCON (NMsoftware) that allows for instant digital file sharing without giving access to PACS. The system has been a success, allowing hospitals to manage head trauma cases without transfer. It is currently set up for 12 or so hospitals around the state to be able to share images with the regional Level One trauma center. A similar coverage system for stroke patients is currently underway.

As we move to expanding health information exchanges (HIE) we must also look at how we can quickly route such time critical data. Ideally the image set can be bundled into a single file using lossless compression and sent to the destination facility where it would automatically notify the trauma center of its availability. The facility would then open the study with their PACS tools and proceed with evaluating the incoming patient.

HIT: not all about IT

Much money is spent on clinical applications and too often we say hospitals have developed isolated silos of information. EHR will hopefully remedy this situation, but frequently the selection and implementation of a new specialty application is conducted with a focus that is too narrow. This results in different groups being dissatisfied and also delivers less than stellar returns on the investment. Clinical applications might have a computer program at their heart but they are hugely multi-dimensional and a successful project needs more focus on the elements often regarded as peripheral.

For example, the implementation of an emergency department information system (EDIS) needs to integrate with the rest of the hospital systems (hospital information system, pharmacy, radiology, lab, respiratory therapy, environmental services, communications, clinical data repository, billing, etc.). This requires planning for, and evaluation of such things as compliance issues, legal aspects, metrics for performance, incorporation of quality initiatives, workflows and workflow redesign, user interfaces, user buy-in, unexpected obstacles, common dictionaries, order sets, formularies, handling referring and primary care physicians, granularity of access, and exchanging data with other facilities. The preceding list illustrates some of the complexity involved when integrating with enterprise applications and the need to lay a solid foundation to ensure outcomes when moving to a new clinical tool.

The old saying of measure twice, cut once applies in this situation. Being prepared with knowledge and commitment will make the IT portion of the implementation that much easier.