Workflow in Ultrasound Reporting – Past and Present Practice, with an Eye on the Future

Workflow overview
There are as many workflow options as there are ultrasound equipment manufacturers, with each practice aspiring towards the same end goal: practitioners, sonographers, ad-ministrative and support personnel want to get the work done as efficiently and accu-rately as possible while allowing physicians and other personnel more time with the pa-tient. Scan, document, review, diagnose and report are only the beginning. You still have to bill, notify the primary care provider in a timely manner and, from a medical-legal per-spective, archive the report and images, sometimes for more than two decades.

Each workflow is a function of several factors:

1) The technology available
2) Network infrastructure (connectivity)
3) The habits of the people using the technology
4) Budgets
5) The skill sets of the people involved
6) Patient volume
7) Whether the practice is self-referred or a referral center

Often, the human component of workflow proves to be the most difficult to harness. In most instances, physicians, sonographers and IT have the most complete understanding of their job and their goals; however, their expertise is limited in scope to the specific ex-pertise and workflow for which they are responsible. The physician and sonographer will be experts in the clinical arena, while the IT professional would be knowledgeable in the areas of connectivity and hardware. And of course, administrators will chime in with their own particular and essential point of view. Often in a networked environment, indi-viduals are unaware of how their role impacts the big picture. Our involvement in numer-ous engagements, with exposure to a wide variety of vendors, has taught us that it is im-perative that the workflow analyst facilitates communication among the various partici-pants to achieve a satisfactory result.

There are really two different models of physician involvement in ultrasound imaging. The image-centric or more familiar Radiology model is typical of the scenario in which physician interaction with the patient is limited and sometimes non-existent. The physi-cians are reading and interpreting static images or small cine loops generated by the sonographer along with a worksheet (hand written, ultrasound-generated or computer-generated), preliminary report, or other supporting information. The physician then either accepts the results, sends the study back to the sonographer, or modifies the findings be-fore developing a diagnosis.

The report-centric model seems to be favored by many MFM specialists or OB/GYNs who have greater patient and/or image acquisition involvement, often interacting with the patient directly and providing preliminary results prior to discharge from the ultrasound lab. Physician interaction typically improves patient satisfaction, reduces the number of patient call backs and is beneficial for the physician in completing the final report at the time of the exam.

In both of these scenarios there is ample opportunity for interruptions from staff, pages, phone calls and other patient responsibilities before finally generating the report and ar-chiving it in a paper file or scanning it into the practice’s EMR. Faxes and/or emails are then sent to the referring provider or uploaded to a web portal for access and review of the report and/or images.

Prior to various agencies, including ACOG and ACR, establishing documentation stan-dards based upon the type of exam being performed, there wasn’t a clear path or standard for documentation. Today, a practice’s criteria for their documentation are generally de-pendent upon clinical findings and overall billing requirements. Often, the lack of a strict protocol for performing and documenting key exam data can lead to lost revenue, incon-sistent documentation and potentially poor clinical outcomes.

A brief history of electronic ultrasound reporting
In the early 1980s, guidelines for documenting ultrasounds were virtually non-existent. Radiologists performed most of the exams and the ultrasound relationship between pri-vate practitioners and MFM practitioners was in its infancy. For the majority of practices the sonographer did the greater part of the physician-supervised scan and made some notes or developed their own forms translating what they saw on the screen for review by the doctor. Once the sonographer completed a scan, some physicians would scan for a few minutes prior to reviewing the notes, as well as the images (Polaroid, thermal – which came later in the 1980’s – or film images), and then would make a diagnosis. The notes went into a file and a transcribed report was mailed to the referring provider. That was the entire report workflow.

While templates helped streamline and somewhat standardize the documentation of an exam, there were still gaps, lots of writing or typing, and the inability to serialize data and communicate with other systems (e.g., PACS, EMR, HIS/RIS) within the practice. Some practices kept better records than others and practices with multiple reporting physicians often would have inconsistencies between reports due to the absence of a standardized reporting protocols or consistent biometric algorithms. Generally, everything went into a file folder with the patient’s name and ID number on it. The hardcopy images also went into the file folder.

During this era, insurance companies were paying handsomely for ultrasound studies and ultrasound scanners were becoming easier to use and more affordable during the 1980s and even more so in the 1990s. The financial flexibility provided by generous reim-bursements (relative to today’s reimbursement rates, adjusted for inflation) accelerated the use and penetration of ultrasound into the private office. Moving ultrasound into the private office generally improved patient care and was obviously profitable. New tech-nology arrived, such as trans-vaginal probes, increasing the economical upside and diag-nostic capabilities with minimum effort.

Eventually, insurance companies began looking for a way to influence utilization while managing their expenditures and reimbursements. In an effort to control rising healthcare costs and elevate the benefit of the procedures they reimbursed, some insurance carriers looked to Accreditation guidelines or bundling ultrasound sessions as part of the overall care package (e.g., Pregnancy) as cost containment mechanisms. As a result, the physi-cian’s average revenue per procedure began to shrink, putting more pressure on maximiz-ing workflow efficacy.

In the 1980s, some of the first ultrasound reporting solutions began to appear. Ultrasound manufacturers began to investigate how to streamline workflow, looking towards ena-bling the export of biometric information to these reporting solutions to reduce data entry errors. Sonultra developed the first ultrasound reporting system private labeled and dis-tributed by a major ultrasound equipment manufacturer. The information captured by the scanner was downloaded to a PC and compared to previous exams and serialized on a graph for easy interpretation and comparison to prior data. However, the printed report still went into a file folder, but the improved workflow was a step in the right direction.

With the exception of an integrated scanner project Sonultra engineered with a major ul-trasound manufacturer in 1997, sophisticated ultrasound reporting software has always resided in a computer linked to the ultrasound scanner. The data from the scanner was captured and formatted into a clean, usable report by the software. Point & click opera-tion and drop-down menus were just a couple of the features that were introduced over time, improving efficiency and reducing costs.

In the past, practices would schedule Obstetrical ultrasound exams every 45 minutes with report distribution measured in days. Gradually, scheduling times shrank to 30 minutes (with many facilities eyeing a time between patients of 20 minutes per exam) and with auto faxing, e-mailing and web based report portals reducing report distribution to hours or even minutes. With the introduction of pick lists and options for global defaults and an integrated ultrasound knowledgebase providing easy detailed searchable accounts on hundreds of anomalies, the reporting software evolved into a powerful tool which re-duced the amount of time to complete each report even further and streamline report dis-tribution. Image archiving and digital storage eliminated the trusty file folder. Technol-ogy improvements were small but each one improved turn-around, if only a little bit. Add it all up and the time to produce a professional looking report went (in most cases) from between ten to twenty minutes to between one and five minutes.

Managing interruptions and maximizing automation
The idea behind all of these innovations is to reduce the number of steps to complete a task, thereby reducing the opportunity for interruptions and shorten the time to complete that task.

Workflow automation proved to be the perfect tool for addressing issues such as stan-dardization, gathering statistical data and enabling HIPAA compliance. It also stream-lined many administrative tasks, including coding, billing, scheduling and report distribu-tion. As workflow and productivity improved, patient care generally also improved.

Presently, most ultrasound scanners can produce reports but the process is not very effi-cient, tying up the scanner and leaving report distribution and archiving to the user. Ultra-sound scanner reports are generally not very flexible and tend to be rudimentary in their layout and appearance. As the ultrasound scanner occupies a critical intersection in the workflow, any delays in generating reports will cause a bottleneck that can negatively impact the practice in a number of ways. A Point of Care solution has to be very efficient so that bottlenecks are non-existent and the utilization of this essential piece of diagnostic equipment can be maximized.

In most of today’s scenarios, the workflow process is basically “store and forward” in-formation to successive stations until all of the varied processes are completed. It is a method that has been refined over the years in small increments but it has limitations due to its essentially static nature. Now it’s time to look beyond this static paradigm to a dy-namic process that can simultaneously resolve multiple responsibilities (billing, statistics, report distribution, archiving), resulting in significant workflow improvements.

The future of electronic ultrasound reporting
Computer automation workflow should improve the natural workflow of physicians, sonographers and support staff by removing inefficiencies, enhancing the accuracy and reliability of the data and the ability to share that data. It should allow multitasking with-out changing people’s natural work habits. Automation has proven invaluable in regards to statistical analysis, report and task distribution and archiving. What other steps can we take to improve workflow?

Today, Point of Care Management is a popular approach to improving workflow and re-ducing expenses. Often, Point of Care refers to simply being able to read an exam at the time that the study is performed and does not generally include generating a report and performing all of the associated administrative functions. But let’s step into the future and look at the possibilities available utilizing current and forthcoming technologies. As a general rule, it is better to complete what you’re doing when you’re doing it. How can we achieve this?

Imagine a solution that selects the appropriate procedure and diagnosis codes based on the report you generate and then automatically populates your billing and statistical analysis programs. Imagine a solution that allows you to sign off on a report and auto-matically distributes the report to the appropriate referring provider and archives it in their EMR, HIS/RIS or PACS System. Now imagine all of this happening just with a few clicks of a button on your ultrasound scanner or a PC on your network. How will that af-fect your workflow?

Interruptions are, of course, the bane of every practitioner and one of the goals of any workflow design should be to reduce the opportunity for interruptions. The advent of EMR’s, hand-held workstations, as well as other technological innovations invites an-other look at the traditional workflow plan.

Consider this Point of Care Management wish list in an Ultrasound Reporting system:

• Capitalize on familiar, proven processes.
• Integrate with other systems including PACS, EMR, HIS/RIS, billing, no-tification and archiving.
• Provide an intuitive interface with a gentle and fast learning curve.
• Remove or minimize obstacles such as interruptions.
• Utilize the reporting software incorporated into the scanner.
• Network multiple Ultrasound Machines, regardless of manufacturer.
• Increase system flexibility to preserve continuity of data.
• Streamline training via common interfaces.

The goal of an effective workflow model enables the practitioner to review, compare and issue a diagnosis, all during the course of an exam. Once the report is electronically signed, the related processes are all triggered by the reporting solution and the job is complete.

More than a decade ago Sonultra partnered with a major ultrasound manufacturer to en-gineer the first generation of point of care ultrasound scanners. The solution was success-fully accepted by the medical community; however, the infrastructure to support a true integrated point of care solution was not in place.

Progress in the area of connectivity, standards and systems integration is already here and becoming more commonplace. As the infrastructure of ultrasound equipment continues to mature, it is only a matter of time before we see a truly integrated Point of Care Ultra-sound Solution.

Mobile computing and wireless point-of-care solutions offer tremendous
potential for today's healthcare industry. These technologies give healthcare providers timely and secure access to patient records and test results whenever and wherever they need it. The benefits to healthcare organizations are significant. Fewer medical errors, elimination of duplicate data, improved accuracy and decreased operating costs are just a few of the ways these solutions can help providers improve patient care.

With so many options available, achieving improved workflow requires an archi-tect/facilitator to identify the options, measure them against your current system and in-troduce appropriate technologies and new workflow options to produce the desired re-sults.

Ultimately it is the suggestions from end users that are the inspiration that drive existing and future solutions like the ones engineered by Sonultra. Now we just have to figure out how to reduce those remaining, pesky interruptions.

About Don Parker
Over 20 years, Sonultra Corporation has emerged as a premiere reporting solution with a successful history of engineering private label and integrated solutions for the top ultra-sound equipment manufacturers. Don Parker is recognized as an expert in Ultrasound Workflow Analysis, Design and Implementation. Years of sharing experiences, multiple workflow scenarios and the dynamics of connectivity continue to provide opportunities and insight for improving workflow. He can be reached at (310) 557-1750 or (877)-SONULTRA.