Optimizing reading protocols: At Legacy Health, a never-ending job

Those who think PACS optimization ends following a successful implementation should think again: Thirteen years after Portland, Ore.-based Legacy Health implemented Synapse PACS, the work is ongoing to keep 50-plus radiologists happy and maximally productive.

Since the implementation, the PACS has grown to serve six hospitals and approximately 30 clinics in two states (Oregon and Washington). Last year, Legacy upgraded and brought FUJIFILM Synapse application trainers on site to train in new functionality.

Looking ahead in an effort to better manage the information needs of a complex health system, Legacy plans to consolidate its six federated Synapse PACS databases into one single enterprise database.

Until that project is completed, Legacy meets radiologist demands for prior studies across the six PACS through Synapse Commonview. According to Joshua Arce, BSRS, RT, ARRT, CIIP, manager of information services for Legacy Health, “We use an enterprise medical record number for the patient, and we use Fuji’s CommonView. This enables us to do cross-database comparisons with ease, so we certainly have been lucky there.”

As technology and radiology has changed over time, adapting the user interface to individual radiologist changing needs is a challenging and ongoing process headed by Arce and his team of PACS administrators.

At Legacy (and likely everywhere else), some radiologists who started their career with film initially tried to mimic film hanging-protocols. “As new radiologists were brought into the practice and those who have been practicing for a long time are exposed to new ways of doing things, the needs of the radiologists have evolved,” Arce says.

In the world of PACS, when it comes to ensuring user satisfaction and thus maximizing radiologist productivity, seeing to each radiologist’s personal preferences is a high priority. Says Arce: “I would say that it is near paramount.”

Getting satisfaction

Initially, when onboarding a new radiologist, there is a fair amount of dialogue back and forth between the radiologist and the PACS administrators, Arce notes.

Over the years, Arce has developed a few shortcuts that aid in cutting to the chase: He identifies the two radiologists in each practice whose reading styles are diametrically opposed and asks the new radiologist which of those is most like theirs. “Sometimes, it’s neither,” he said.

At the same time, thanks to the deep pool of 50 radiologists, the PACS administrators have a robust reading-protocol library from which to share and make suggestions.

This keeps Legacy PACS administrators from having to reinvent the wheel with every onboarding and updating, Arce says. “Then, if they want to add steps or take a look at a reading protocol using a different DICOM attribute, it can certainly be modified,” he adds.

At Legacy, with its wide geographic footprint, this challenge has been magnified by differences between suburban hospitals, which largely feed off general radiology, CT and MRI, and their city counterparts, which can be heavily specialized for neuro, orthopedics, pediatrics, trauma and other service lines.

“One of our facilities sees a lot more oncology workups, including molecular imaging, than the others,” Arce says. “The toolsets for tracking lesions and patient progress in response to cancer treatment are more important there than in the more suburban hospitals. It’s safe to say that Synapse PACS delivers well with the fairly diverse needs of the different radiology practices.”

“We do an assessment based on modality type,” he adds. Arce and team ask a lot of questions, including:

• How would you like to see your MRIs?
• How would you like to see your plain films?
• How many priors are you interested in?
• Do you prefer to compare across all body parts?
• Would you rather do just body part-specific and modality-specific views initially?

Dealing the DICOM deck

Fujifilm’s DICOM-based Reading Protocol Editor has exponentially expanded the ability to customize the reading environment to the individual radiologist using DICOM properties, Arce says.

“It’s kind of like dealing cards,” he explains. “If you are using all of the elements, all of the DICOM properties, you actually are now playing with a full deck. Otherwise you are playing with maybe two suits, hearts and diamonds. And, really, you need a lot of other options to make valuable reading protocols.”

Time, sequence, laterality and other DICOM properties can be used to create powerful reading protocols, Arce says.  

By contrast, if the only “playing card suits” on the table are series name and date, as was the case before the DICOM properties came into play, you might as well go back to film, Arce says.

“By using the DICOM properties, you have a lot more flexibility,” he explains, “and you can customize to a radiologist’s preferences.”

Legacy has learned that PACS optimization for subspecialist satisfaction begins with tasking Synapse to provide appropriate worklists. The worklists can be set up to display the studies that the subspecialist is reading, effectively eliminating “hunting and pecking.”

“We have fairly specific worklists based on the radiology group’s preference,” Arce notes. “We attempt to have folders and worklists that match radiologist schedule, specialty, and overall preference, down to time of day, body part, image and modality type, so we are fairly flexible in that regard.”

Amping up productivity

Customizing reading protocols not only increases radiologist satisfaction, it also increases their productivity, according to Arce. “We’ve noticed that the reading protocols are the biggest factor in increasing productivity for radiologists,” Arce says.

Auto-comparison and what Fujifilm calls “Reading Steps” can make a big difference in streamlining the reading process. Arce offers the example of building a reading protocol for a basic two-view chest x-ray study with one prior study.

“Some radiologists would like to see both current and prior PAs, one on each monitor,” he begins. The next “step” would be both laterals compared, and in the final reading step, both current projections, the PA and the lateral, would appear side by side on the monitors.

“That way, they are not having to perform a lot of drag-and-drop or a lot of scrolling through images,” he notes. “It’s just three clicks and they are done.”

CT or MR can be managed the same way. “Radiologists may set up the comparisons very specifically so that they are moving through comparisons with just a few clicks, thus increasing efficiency and accuracy.”

Mission critical PACS optimization

At Legacy Health, the goal to keep pace with advances in PACS technology and optimization sometimes seems never ending.  But the commitment of PACS administrators in weaving the old with the new in order to help radiologists achieve maximum efficiency and satisfaction is mission critical.

The use of tools such as CommonView, which makes access to prior studies almost seamless, in addition to Fujifilm’s DICOM-based Reading Protocol Editor, and filtering worklists to drive images by subspecialty, have allowed Legacy Health to achieve high radiologist satisfaction and efficiency.

As Arce puts it, “We are dedicated to delivering the best tools out there to our providers and will continue to evaluate options, communicate with radiologists to understand their needs and upgrade our systems to achieve this goal.”