Patient Informatics

Site: ISRRT e-Learning
Course: International Covid-19 support for Radiographers and Radiological Technologists
Book: Patient Informatics
Printed by: Guest user
Date: Monday, 15 August 2022, 11:48 AM

1. Overview

This module focuses on the main challenges to be considered by Picture Archiving and Communication System (PACS) teams or other individuals who support the I.T. functionality of Radiology services, which will also be affected by the provision of imaging during this outbreak.

The majority of informatics support during outbreaks or prolonged major incidents such as found with COVID-19 focuses on reducing ‘imaging drag’ (the micro-delays found within all imaging processes which cause bottlenecks and frustrations due to suboptimal processes and workflow – most likely to become visible in high-intensity situations)


Sections

  1. Setting up and connecting temporary imaging facilities for COVID-19 imaging
  2. Integrating temporary, donated or non-standard imaging equipment with existing workflows and Patient Administration, Radiology Information System(RIS), PACS, Electronic Patient Record (EPR) etc.
  3. Ensuring good quality electronic patient documentation
  4. Consistency of imaging documentation
  5. Ensuring prompt and reliable information flows (integrations into the wider hospital environment)
  6. Image storage and retrieval
  7. Radiation dose recording and monitoring during high volume operations
  8. Prompt and efficient Image Transfers (as patients are moved between centres / temporary centres
  9. Security and access for temporary / redeployed staff / students
  10. Faults, managing housekeeping, on-call and informatics support / administration
  11. Imaging I.T. Equipment and Infection Control
  12. Reporting outside the hospital environment
  13. Considerations for (future) research – labelling and identification of relevant examinations
  14. Security and cyber considerations
  15. Returning to normal service / standing down

2. Setting up and connecting temporary imaging facilities for COVID-19 imaging

Countries around the world have seen the creation of temporary hospital and ‘overspill’ imaging facilities. These are typically located in conference centres, leisure facilities, stadium, gyms or public halls - “external sites”. However they may also be within hospital grounds (in marquees, tents or in containers etc.) – “internal sites”.

For both internal and external sites, the main considerations for imaging informatics are the availability of trained staff, networking, connectivity to utilities and access control / security.

For internal sites or those external sites close to regular healthcare institutions if there is a local hospital with I.T. infrastructure having capacity (networking, servers, switches) available then it is by far the best option to join into their infrastructure and simply adopt their already established procedures and governance.

For external sites not close to existing healthcare infrastructure, a choice would need to be made between self-sufficiency (effectively procuring and then setting up and commissioning a full hospitals services, albeit temporarily) or ‘shuttle-running’ (borrowing resources such as radiographic acquisition equipment, workstations from an established hospital and feeding data back on, for example, a daily basis by the exchange of portable hard drives etc.). The first option obviously has advantages, but is far more costly and requires multiple suppliers and parties to work at speed to set up.

In either case, the actual approach taken will be determined by the imaging modalities and volumes expected. There will be a need for local protocols and standard operating procedures to be designed particularly to take into consideration any new I.T. deployments and also the need to maintain the infection control of the equipment, from keyboards to screens and other contact points.

3. Integrating temporary, donated or non-standard imaging equipment with existing workflows and Patient Administration, Radiology Information System (RIS), PACS, Electronic Patient Record (EPR) etc.

Many hospitals around the world find that additional imaging equipment such as mobile DDR units, relocatable CT scanners and portable ultrasound kits to meet the demand for additional chest and thoracic-related imaging are either offered or provided by commercial organisations or governmental efforts. These new units need to be rapidly integrated into the existing I.T. infrastructure and workflows.

Firstly, ascertain the condition of the equipment – is it new or does it potentially contain other incorrect configurations? Does it require specialist (manufacturer) attendance to make the connectivity changes? Make any arrangements with the manufacturer to attend if necessary.

Secondly, consider ‘hard estate’ factors which mainly form a checklist for the installation, but require much more rapid action for any missing or insufficient items – do you have enough power, or need power supplies provided by your estates departments or even by a local power company? Do you have enough power protection devices (UPS)? Are there physically enough network cables, network switches and capacity on the existing network, servers and storage devices (usually a PACS, but potentially just network shares or standard hard drives). Will any PACS require licence upgrades? Will your storage providers (PACS) need to make a connectivity change also on their systems?

Thirdly, consider ‘soft estate’ factors - wherever possible standards and resources such as DICOM (Digital Imaging & Communications in Medicine), HL7 (Health Level 7), FHIR (Fast Healthcare Interoperability Resources), and IHE (Integrating the Healthcare Enterprise) should be adhered to allow integration and future interoperability between systems.

Obtain the equipment DICOM Conformance Statement and be sure your existing infrastructure will support the equipment (else it can be used as a stand-alone device, but this generally is unsatisfactory due to the increased burdens on imaging personnel having to manually reconcile imaging). Work through a list of your existing systems (e.g. RIS, EPR, PACS, electronic requesting etc.) and work with each team in parallel to make the necessary connections. Having not only efficient workflows, but keeping these as close to the existing workflows as possible will help clinical staff and reduce ‘imaging drag’.

4. Ensuring good quality electronic patient documentation

All clinical examinations of any kind must contain accurate and securely recorded detail. As a minimum, data that should be captured will be the information on a standard request form:

  • Patient salutation, gender, first and last name;
  • Patient date of birth;
  • A unique identifier for the patient (hospital or other national number);
  • The source of referral (ward or department) – who the results should be shared with in the absence of the requesting clinician;
  • The requesting clinician and the clinical information supplied by them (examination requested, reason for examination, clinical question to be answered);
  • Date and time of exam;
  • Unique identifier for each image or imaging acquisition (usually an accession number), along with the orientation of any image, laterality;
  • The total number of images.

If no suitable I.T. system such as a RIS is available, then a spreadsheet application such as Microsoft Excel, Google Sheets or even a suitable paper book may be used.

It is important that the initial acquisition, generation and recording of data is accurate, as amendments at later dates are harder to make.

5. Consistency of imaging documentation

Ideally, imaging documentation will remain consistent across regions and nations. Many international standards for radiological data collection and presentation exist, but it is recognised that these are not universally followed or even implemented by manufacturers.

Utilising at least the minimum data sets presented in Section 3, this data needs to be fed back to any surrounding systems, and likewise any updates passed down to Radiology input onto the Radiology systems. Of particular interest are corrections to patient demographics discovered after imaging acquisition, and any death markers (which would remove the need for a rapid report to be issued, allowing for reporting resources to prioritise the living).

6. Ensuring prompt and reliable information flows (integrations into the wider hospital environment)

The 4 main standard information flows within an imaging procedure are:

  1. Patient is examined and the region (body part / symptom) of interest is identified by a clinician. The referral to Radiology follows agreed clinical referral guidelines
    1. This initial consultation is documented electronically with an agreed minimum data set and shared electronically or printed for the patient/carer;
    2. If there is a process to obtain any other results required to corroborate results (such as laboratory blood tests or previous imaging) this should be initiated.
  2. Diagnostics Performed:
    1. Imaging information captured to include necessary text, image and dose information
  3. Results
    1. Interpretation and capturing in a format that can be shared and possibly coded for ease of future aggregation (to support research or statistics / post event review)
    2. Interpretation may be local (i.e. completed in the hospital by a Radiologist or suitably trained Technologist) or remote via telemedicine (i.e. reporting performed in another location outside of the hospital).
    3. Templates (stock text) can be prepared and used to ensure all data captured and a standardised format – increases speed at which reports can be issued plus the speed at which the results can be interpreted by clinicians for treatment.
  4. Result Distribution
    1. In its most basic form, rapidly conveying reports is crucial. Speed is of the essence in COVID-19 patients.
    2. In an established informatics environment, the standard posting is to Electronic Patient Records, Patient Health Record, Community/Primary Care Systems is acceptable; in a manual paper environment, multiple copies of the report should be dispatched via the usual processes.
    3. There must be an ability to recall patients if necessary due to poor imaging identified or the need for further projections / examinations to rule out other pathologies or causes as necessary
    4. Management Reports for local, national, or international use
    5. Consideration on how image transmission can take place if required to other sites or workstations (for example if specialist interpretation of complex imaging is required).

7. Image storage and retrieval

The storage and distribution of imaging acquired from COVID-19 diagnostics is a paramount importance to effective treatment of affected patients.

In order to achieve a smooth workflow, consider the following key points:

  • Will COVID-19 imaging acquired in temporary or external location be stored separately to the usual workflow imaging or mixed in (perhaps identified by Station Names, or other worklist parameters)?
  • Can imaging be stored with full demographics (perhaps from a worklist) or does the data need to be quarantined for later manual housekeeping?
  • Access and sharing requirements – do the images need to be shared more widely than normal? Will there will more temporary staff needing access to the systems?
  • Are existing image compression settings appropriate? No studies are as-yet available comparing variously compressed COVID-19 thoracic imaging.
  • Is the storage media large enough? Secured?
  • Take regular backups and follow standard good data protection advice to guard against corruption or misidentification.
  • Will network connections such as WiFi be satisfactory or do new links need to be commissioned?
  • For services previously reliant on off-site (Cloud) storage – are there sufficient local resources to store current and recent images in case access to the cloud is lost?

8. Radiation dose recording and monitoring during high volume operations

Monitoring of both staff and patient radiation doses are particularly important during high volume ‘crisis’ operations.

Patient monitoring: as usual, this would ideally be captured electronically from the modality and the dose plus exposure factors utilised passed to the RIS or recorded on the request in any other way. A consistent dose unit should be chosen for all examinations to alleviate the need for conversions.

Staff monitoring: this can be achieved by more rapid rotation of film-based dosimetry badges (changing the badges more frequently), the use of TLDs, or the use of newer instant read technologies available in some markets. Decisions relating to this would be made by the local Radiation Protection Supervisor and records should be kept updated more frequently than usual in order to ensure no increased harm is being made to staff health.

9. Prompt and efficient Image Transfers (as patients are moved between centres / temporary centres

Mentioned previously, many centres have found the need to move imaging for one or many patients in the following circumstances:

  • Patient deterioration – requires more advanced investigations or treatments than those available locally;
  • Patient recovery – no longer requires specialist centre and can be moved to a lesser advanced facility to ‘free up beds’;
  • Lack of reporting staff – imaging and tests must be reported remotely due to a lack of suitably trained staff locally;
  • Governmental order or health policy – perhaps all confirmed COVID-19 cases are clustered into one or more ‘supercentres’ for efficient treatment or containment.

In all these cases, consider how existing infrastructure can be best utilised. Obviously in a region without reliable internet connectivity, manually conveying CDs (ensure sufficient stock of the correct media is held), thermally printed digital films etc. are the main choices. However even in areas with usually ‘good’ public internet, lockdowns and social isolation guidance is placing pressure on standard network connections due to the increased use of homeworking and even consumption of ‘Netflix’ or Youtube videos! As a result, for those healthcare institutions with good connectivity traffic prioritisation or ‘shaping’ may be needed in conjunction with local I.T. or internet service providers in the country.

Dedicated facilities for rapid image sharing are provided by many PACS vendors.

XDS and XDS-I (Cross Enterprise Document Sharing – for Imaging) is the best practice standard to use if transferring to another hospitals PACS or imaging system. For those without direct connections to destination PACS there are a number of intermediary solutions used to transfer millions of Radiological images daily between hospitals, also allowing for online viewing and manipulation in case the recipients do not have a high quality graphics-processor enabled PC in the remote location. The largest such system currently in use in North America and the United Kingdom is the Image Exchange Portal. Many other vendors and smaller companies in different regions provide similar services and local solutions (peer-to-peer) are likely to be very helpful and rapid to deploy in current circumstances.

10. Security and access for temporary / redeployed staff / students

Many countries report increased thefts of clinical equipment and attempts in impersonating healthcare staff in attempts to gain access to restricted areas or equipment.

Consider the physical security of all equipment, particularly if it is unique or irreplaceable. Place these items deep within staff areas and ensure they are checked and watched over if needed. Be aware that portions of populations are becoming financially challenged by the outbreak affecting routine income and this may lead to unusual behaviours. Consider fire and flood proofing in case of social unrest.

In terms of non-physical security, volunteers may need user access to Radiology computer systems rapidly and their access may need monitoring or controlling more tightly than regular employees.

Have ‘break glass’ usernames (accounts set up in advance for specific individual uses, but where the names of those people are not yet known) ready to hand out in envelopes in case of a major influx of cases requiring massive amounts of assistance. Have a process in place to rapidly review, grant or revoke access requests. Auditing of accounts is also very important to prevent (or detect) data theft attempts or corruption.

Administrative accounts should remain tightly controlled, but consider planning for the potential loss or incapacity of administrators and who would take their place – is there sufficient written documentation to cover any absences?

11. Faults, managing housekeeping, on-call and informatics support / administration

When I.T. systems of any degree of complexity are stressed, or are used by relatively unfamiliar individuals faults are more common. A standard operating procedure for raising and resolving faults should be adopted, ideally through a single point of contact to ensure there is co-ordination for rapid response.

In a smaller environment, this could be performed through a database or spreadsheet but if there are multiple users then electronic tools could be used to provide tracking across multiple responsible owners and shifts.

If spreadsheets or paper documents are to be used collaboratively then procedure for managing and reconciling these files needs to be developed to ensure that as documents are amended it is on a shared copy not a local copy. A minimum data set also needs to be agreed so that if a user develops a fault but is unable to contact anyone immediately then they know what information to collect and record for later action.

24/7 operation of informatics support should be considered in larger environments – remembering that an extra hour in fixing a critical I.T. issue may cause increased deaths or backlogs exponentially to that expected in normal operation.

As with all non-standard operations, more frequent backups of imaging data is expected, and having plans and the supplies in place to support this is helpful.

Standard plans for informatics teams such include the layers of escalation if a senior administrator became themselves incapacitated (does anyone else have server access / administrative passwords etc.?), as well as revised shift patterns for any extended support hours working, allowing for sufficient time for rest and respite.

12. Imaging I.T. Equipment and Infection Control

Much of the equipment provided by Radiology I.T. departments and PACS teams is at risk of contamination due to it being manipulated in the presence of patients or being used by multiple people in high-risk environments.

Due to the sensitive (electronic) nature of the equipment though I.T. teams therefore need to consider issuing cleaning guidance for each piece of equipment they manage.

Manufacturers are best placed to provide guidance, but more generally when answers are not forthcoming:

  • Most patient facing equipment in this context (mobile x-ray machines, ceiling mounted x-ray machines, CT scanners etc.) are designed to be wipeable with approved cleaning solutions.
  • For screens, keyboards, mice the guidance would be the same as for standard barrier nursing techniques:
    • For non-touch screens (standard PC monitors) apply a clear plastic bag over the equipment before coming into contact with it.
    • For resistive technology touchscreen monitors (those being the touchscreens which normally work fine with medical gloves on) cover them with a cover plastic bag if they are freestanding (i.e. on their own arm) or use masking tape (not skin tape which leaves residues) to tape a cut square of clear plastic bag over a screen set into the machine;
    • For capacitative touchscreen monitors (those needing bare fingers to register a touch) use any cleaning product recommended by the manufacturer as long as it doesn't get too wet.
    • For peripherals such as keyboards and mice, use damp (but not wet) cleaning wipes. Waterproof models are sold for immersion and may be useful to consider in high traffic areas.

Monitors are the most commonly damaged piece of Radiology I.T. equipment during cleaning. Most damage is caused by either 1) too much moisture 2) too much scrubbing (e.g. paper towel drying is abrasive to the surface or 3) sharp object penetration (even a fingernail). Monitors cannot ever be sterilised by chlorine agents due to the types of surface used for the display unless they are set in or installed behind a protective sheet of glass etc. (similar to screens on theatre walls are now made).

13. Reporting outside the hospital environment

Some countries reported an increased desire for reporting staff to ‘work from home’ during the outbreak. This may reduce the risk of infection to reporters but also may not be possible to achieve depending on whether those staff may be required to cover other duties (clinical duties if they hold medical registrations or licenses to practice medicine). However the following considerations may be useful in setting up such as service:

  • Is the public internet robust enough to allow for remote reporting? As mentioned previously, many countries reported capacity issues with large volumes of the population contained to homes;
  • Is it possible to move Radiology reporting workstations and monitors to reporters homes or would it be more convenient to move them to, for example, local hotels where more use could be made of them (but still out of the hospital boundary);
  • Are there sufficient workstations within the department to begin removing them?
  • Is there I.T. support for configuring firewalls, virtual private network (VPN) access?
  • Licensing – are there sufficient licenses for software such as the PACS, RIS and general I.T. components (VPN etc.)
  • Worklists – can the necessary worklists be compiled for expedient remote reporting?
  • Support for technical problems – can adequate support be provided outside of the hospital boundaries? Moving equipment remotely generally adds exponentially to the time required to support fault finding problems etc. which may not be possible to provide during extremely busy periods.

14. Considerations for (future) research – labelling and identification of relevant examinations

As with the 1958 and 1967 influenza outbreaks, retrospective research activity on the COVID-19 outbreak will be extensive. All healthcare institutions can be responsive and assist with this by ensuring that examinations and the surrounding data can be accessible in a timely manner, meets regulations and maintains patient confidentiality. Use of standardised terminology (such as the internationally designed SNOMED-CT nomenclature or other national coding scheme should be used if the resources are available. If there is the ability to label or mark key images on the storage system this should be used in a standardised manner – consulting with not only internal users, but surrounding hospitals too will help with this.

15. Security and cyber considerations

In organisations with developed I.T. infrastructure, an increased alert should be maintained for cyberattacks, in particular the deployment of Ransomware or similar malicious applications. Although most organised groups of malware vendors have indicated publicly that they will not knowingly attack healthcare targets at this time, the current timing would be perfect to most likely extract cash payments to remove any disruption to services that occurred.

Good cyber security should include the use of latest supported software on all Radiology PCs and equipment (including CT scanners, DDR mobiles and ultrasound machines etc.) which is up to date with all high priority and security updates performed ideally within seven days of release. Password security for all user accounts should be increased, particularly for higher level administrative or server accounts all default passwords disabled.

An agreed process to assign users, recording the approver, permissions level if applicable, due date for review or revocation should be in place or agreed early on, with the ability for enforced changes to users passwords if a compromise is detected. The use of administrator accounts when working normally should be avoided. Unsupported software and all unneeded software should be uninstalled, with functions such as autoplay and autorun disabled to reduce risks.

16. Returning to normal service / standing down

After the outbreak:

  • Reconcile temporary processes with ‘business as usual’ – try to ensure images and other patient data is presented and retrievable in the same manner;
  • Check, verify and remove all user accounts as needed;
  • Ensure all temporary equipment has data collected and then wiped ready for collection;
  • Audit and recover any loaned out equipment;
  • Produce any ad-hoc necessary statistics for governmental submission
  • Have a ‘lessons learned’ session with the PACS team staff members – is it possible to integrate any of the actions or procedures into normal daily routine to improve the standard imaging service?
  • Update departmental process lists with any changes to usual process.