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To support referrals that are evidence based and best practice and that facilitate the most appropriate DI service provision, maximise health benefit and inform and empower consumers.
The project includes:
1. A brief overview of current systems involved in DI request, examination performance and image/report management;
2. Identification of technical issues which will impact on the further development of ICT; and
3. An outlined draft work plan and key activities for the DI profession to take forward ICT related issues.
This project aims to develop understanding of the current and future role of information and communication technology to address information management issues impacting on the quality and efficiency and consumer experience of diagnostic imaging.
The project team used a methodology based on process and issues analysis to construct a high level assessment of the areas where information and communication technology can make a difference and the blockages or requirements necessary to progress ICT in these areas.
This project overviewed the referral process and radiology workflow, and has created a process map. The report identifies, for each stage of the process, key information management issues, potential e-health solutions and the issues, barriers or tasks that need to be tackled.
MacIsaac Informatics Pty Ltd
The timing is now right to advance the application of ICT in the Diagnostic Imaging sector as the core group of requestors/referrers (GPs) have the ICT capacity and specialists are on the cusp of adopting ICT for clinical work. There are significant benefits to be achieved by completing the cycle starting with the electronic request and ending with the electronic result. The business drivers to moving away from x-ray film to either digital imaging or computerised radiology (CR) are now well established (as widely reported in the literature, in addition to a growing amount of local experience in Australia) and have been attractive enough to encourage many DI practices to move to adopt Picture Archive Communication Systems (PACS) and digital image management.
This project identified a number of key areas of ICT development which require action from the DI sector to achieve:
- The effective introduction of DI technologies into practice and organise appropriate changes to work processes;
- The integration of the various components such as PACS, Radiology information systems (RIS) and X-ray equipment to support exchange of data and integration of workflow;
- The use of computerised requesting, supported by decision support, improved patient education and electronic transfer of the request to the DI service so that the information required is present when the investigation is scheduled;
- The adoption of HL7 standards for messaging results (electronic reporting). Both electronic ordering and reporting are needed to achieve closure of the test request/result cycle;
- A process to gain acceptance by referrers of digital images as a film replacement;
- Access to images for historical comparison and to support continuity of care; and
- Development of a high speed and affordable communication network to support tele-radiology, movement of images within DI services and off-site reporting.
Issues paper (PDF)
Final report (PDF)
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A small case series investigation of the quality of image CDs produced by Australian radiology was undertaken to conduct an audit for compliance with the internationally accepted standard profile for image CDs (the IHE Portable Data for Imaging Profile).
This study was conducted to gather evidence of current practice and to draw the attention of the radiology profession to concerns about quality, usability and acceptability of portable image formats raised by procedural specialists. It is not a definitive discussion of all relevant issues.
Thirty three CDs, containing a CT image and one peripheral joint, were volunteered by radiologists and I.T. companies at the 2007 RANZCR annual scientific meeting. These were inspected, tested with IHE compliance tools from the USA and Germany, and loaded on a number of windows PCs and a MacIntosh notebook computer, simulating the end user process.
MacIsaac Informatics Pty Ltd
CDs were presented with a wide variety of storage methods and labelling. All but one complied with the ISO 9660 standard for CD formats which support cross platform use. All CDs contained a varying number of errors in the use of DICOM. Only one CD used lower resolution images suitable for web viewing on a standard browser. All CDs contained software for viewing images and most of these auto loaded on windows machines. Thirteen different viewing programs were found with the most common being used 25% of the time. The reviewers struggled to learn the features of the different viewing applications in the time provided for testing (1/2- 1 hour per CD). The time taken to load images varied from around half to one and a half minutes. Once loaded the image changeover was a few seconds for many but not all products.
Almost all the reported complaints relating to the use of images off CDs were confirmed within this limited study. The major areas for technical improvement are in the adherence to parts of the IHE profile covering DICOM standards and the provision also of lower quality images in web content format. The use of embedded DICOM viewers is a superficially plausible solution, yet has significant shortcomings when used alone as the strategy to support access to images.
The time to load CDs makes it unlikely that CDs could be used in non-emergency clinical practice, without some form of pre-loading and use of image management software which resides on the users system. It is not clear whether current IT systems are capable of supporting this workflow and whether such a change is feasible or acceptable in procedural specialty practice. To some extent the solutions will need to be developed before cost and acceptability issues can be tackled.
Regardless of how images are transported, there is a need for users to have appropriate computer hardware and software. This is the major technical barrier to implementation of digital image delivery at present.
Final report on CD Challenge
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In response to the outcomes from IHE Part 1 (QR01.ii), this project will prepare and run a technical workshop on the use of IHE profiles for portable media in digital imaging, and produce a draft guideline for digital image delivery on portable media in Australia. The final report will provide recommendations to the QUDI program for further work to support the change management involved in moving to a standards certification process for CDs, and explore options for an open standards model for delivery of images over the internet.
The aim of the project is to provide a standardised solution to the way digital images are presented on portable media, and provide an open standards model for image delivery over the internet.
Technical workshop on portable image media; Preparation of draft guidelines, referring to international standards where appropriate.
MacIsaac Informatics Pty Ltd
The IHE workshop generated significant interest in the IHE profiles among ICT vendors, medical organisations and governments. It has led directly to the formation of IHE Asia-Pacific (www.ihe.net.au) which is committed to the introduction and successful implementation of IHE profiles in Australia and the Asia-Pacific region.
The guidelines for digital image delivery are expected to inform the College’s standards of practice and the anticipated RANZCR/ADIA joint Code of Practice on digital imaging.
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While this project will have relevance for the interaction of radiologists and a range of medical practitioners, the specific scope is to explore enablers and inhibitors to more effective communication and interaction between general practitioners (GPs) and radiologists.
Improvement in communication and interaction are precursors to:
- More effective referral, analysis and clinical reporting.
- More appropriate diagnostic imaging that meets the needs of both craft groups and patients.
- More sustainable programs that have been developed with greater awareness of practice.
The RACGP will use a well developed and tested general practice systems analysis tool, the RACGP Quality Framework, and will pilot and then roll out a series of focus groups with general practitioners and radiologists to explore enablers and inhibitors to more effective communication and interaction. This process will facilitate the identification of gaps in services, communication and knowledge, and the relationship between these issues and more effective referral.
The Royal Australian College of General Practitioners (RACGP)
That the process will provide important information on future directions for enhancing the referral and reporting process between radiologists and GPs, and will pave the way for more substantial collaboration in the future.
The guidelines for digital image delivery are expected to inform the College’s standards of practice and the anticipated RANZCR/ADIA joint Code of Practice on digital imaging.
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The project scope includes the following:
- Evaluation of the overall effectiveness of and issues surrounding the DI referral process from the perspective of the key stakeholders – medical and allied health practitioner referrers, radiologists, patients (consumers) and other parties;
- Within the context of referrals, identification of issues that impact on the quality of care and optimal interaction between referrers and DI services
- Assessment of ‘best practice’ referral information content to identify a core (minimum) set of data required to support DI requests / referrals between referrers and DI providers
It is important to note that the scope of this project is primarily focused on the process once a DI referral has been initiated by the referrer.
The purpose of this project was to provide the contextual framework and confirm the issues impacting the efficacy and quality of the DI referral process. It aimed to identify and outline the benefits of improving current DI referral practice and also to identify a core set of information requirements for DI referrals.
The consultancy approach adopted for this project is based on an Issues Based Consulting methodology. This approach has involved development of a logic framework to direct the investigation involving both stakeholder consultation and research.
MacIsaac Informatics Pty Ltd
Based on a synthesis of findings from the extensive research and stakeholder consultation conducted during this consultancy, quality attributes of the DI request should include:
- Provision on the DI referral / request of adequate clinical information to enable the most appropriate investigation/procedure to be selected (that takes into account patient safety /radiation exposure and diagnostic value)
- Provision of the reason for the investigation / clear diagnostic question that the referred wants answered to assist the radiologist in interpretation of results and completion of a pertinent and concise report
- Legible, unambiguous and properly completed DI request
- Clear instructions for preparation required for the investigation
- Feedback to the referrer from the DI provider that the request has been received
Final report (PDF)
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The project team will:
- Develop a standardised DI paper request form for RANZCR endorsement and recommendation to stakeholder organisations including the Commonwealth.
- Trial and evaluate the use of this form in a variety of contexts (GP, hospital, medical specialists)
- Evaluate the compatibility of such a form with a future electronic referral system, to be based on a template similar to that outlined in QR3.1
The aim of the project is to standardise and improve the way important data is communicated between referrers and radiologists.
The project consists of the following steps:
1. Confirm the form design with QUDI Technical Reference Group
2. Develop a mock up form of usable quality and detail to consult with 3 DI practices (covering 2 private sector and one public sector) about the concept of a generic form, customised with practice logo, site details, phone numbers etc., suitable for handwriting or computer printing
3. Develop a standard methodology for the production of the forms and cost this in comparison with current form production
4. Consult with the AMA, RACGP, and ADIA and Medical Software Industry Association (MSIA) on the form design and likely implementation issues
5. Seek agreement from 2 practices to trial the form and invite a sample of referrers to use the new form for a period of one month
6. Conduct a qualitative review to identify issues with the new and current forms
7. Modify form design based on this input and produce a final report covering design, implementation issues, costs and recommendations for change management
MacIsaac Informatics Pty Ltd
The common DI request referral form:
- Encourages referrers to provide important data to assist radiologists in performing DI examinations and procedures
- Supports improved communication between referrers and radiologists
- Can be customised to meet the needs of DI practices and is acceptable as an alternative to their current individually designed and non standard forms
- May be suitable for hospital and community DI services
- Is acceptable to referrers for both manual and computer production
- Assists the health IT industry by producing a form that has agreed data elements and a standard layout to minimise printing customisation
- Supports the medium to long term move to electronic transmission of referrals
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- Develop a broad set of principles which could apply to all non-medical practitioners seeking rights to request diagnostic imaging services
- Establish principles for determining which diagnostic imaging services should be made available for referral by allied health practitioners
The purpose of this project was to provide a framework of principles for the referral for diagnostic imaging in Australia.
The project methodology was designed to distil stakeholder views into the most critical domains, and to represent key issues to address within those domains. Consumer viewpoints were also leveraged to test emergent themes and offer perspective from the patient journey. The methodology followed four phases: contextual scan, model development, stakeholder consultation, and principles framework development/final report.
University of Queensland
The project used the findings of the qualitative research to construct a framework of principles that should underpin not only considerations of extended access to imaging by new referrers but also a review of the existing structure of the Diagnostic Imaging Services Table (DIST). It revealed some dramatic disparities in the existing utilization patterns of diagnostic imaging both between the various allied health craft groups relative to the utilization patterns by GPs. These disparities are highly unlikely to be explained by patient demographics alone and warrant further investigation.
Final report
Report summary
College response
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This project will:
1. Develop a web-based interface to support the development, publication, and revision and/or updating, of Critically Appraised Topics (CAT) in Diagnostic Imaging.
2. Develop an appropriate training program for qualified radiologists and radiology trainees who wish to undertake critical appraisal of topics in diagnostic imaging for e-publication on the RANZCR website. This should include, but not be restricted to:
- Appropriate small group training program in basic evidence-based medicine theory including:
- How to frame an answerable clinical question
- How to identify and locate the best available evidence
- How to look for the evidence
- Hands-on experience in the use of common medical databases (Medline, Pubmed, Cochrane)
- Where to find guidelines created by other groups that may be applicable to the clinical question
- Experimental and observational study design. Common study designs in diagnostic imaging studies
- Basic biostatistics that are encountered in the diagnostic imaging literature (confidence intervals, p values, relative risk, Odds Ratios, number needed to treat, absolute and relative risk reduction, sensitivity, specificity, positive and negative predictive values, likelihood ratios, effect size, specific methods applied to systematic reviews / meta-analysis)
- How to do structured critical appraisal of diagnostic studies, interventional studies, systematic reviews and clinical guidelines
- Training in undertaking a CAT – suggestions regarding on line and other mechanisms for monitoring / support for this process for groups who have completed basic training
The evidence base developed through this program would:
- Allow the timely development of clinical practice guidelines for diagnostic imaging, that are problem based, topical and clinically relevant to the College and the referring clinicians the development of topical and clinically relevant problem based multi-disciplinary information on specific health conditions that require (in the opinion of the target practitioners or RANZCR or both) guidelines about the use of imaging
- Apply international best practice standards for development of clinical practice guidelines for diagnostic imaging
- Be incorporated into the development of future desktop software for evidence based DI requests
Med-E-Serv Pty Ltd
This project should result in the creation of a College template for Critically Appraised Topics to support web-based publication, evaluation and regular update of critically appraised topics by graduates of the training program, moderated by an accredited panel of College practitioners.
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1. To provide support and training for a Clinical Scholar in searching the literature, appraising identified studies and synthesis of the best available evidence
2. To undertake a literature review to identify risk factors for contrast induced nephropathy following administration of iodinated contrast during radiological investigation
3. To evaluate the training and support process to assess the amount and type of expert assistance required to enable a junior clinician to undertake a rigorous systematic review
The intent of this project is to develop a reproducible methodology for a clinician to undertake a critically-appraised topic in Radiology with expert technical assistance.
Centre for Clinical Effectiveness
By capturing and documenting the process of completing a critically appraised topic and identifying and proposing solutions to problems that occur, this project hopes to assist others undertaking CATs in the future.
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The Fellowships are for early-to-mid career Radiologists with a keen interest in improving health care through the use of best available evidence. Fellows have the opportunity to develop and undertake a project to address an evidence-practice gap in the current practice of diagnostic imaging (based on the QUDI framework).
It is intended that Fellows will develop the skills and expertise to become leaders in the practice of evidence implementation.
The fellowships are offered in partnership between RANZCR, the NHMRC's National Institute for Clinical Studies (NICS), and the National Breast and Ovarian Cancer Centre (NBOCC).
The first two NICS-RANZCR Fellows are completing their tenure in early 2008: A/Prof Stacey Goergen (promoting evidence-based diagnostic testing for suspected venous thrombo-embolism) and Dr Taryn Bessen (improving the uptake of imaging guidelines in the emergency department).
Dr Felicity Pool was awarded the NICS-RANZCR-NBOCC Fellowship in early 2008. Her fellowship project will focus on optimising communication about breast imaging using a structured reporting and classification system.
Poster
Article
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