Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Saturday, May 03, 2008

You Want PACS?

Several people have commented on my previous Rad Rage posts that introducing an electronic Picture Archiving and Communication System will solve all the problems arising from image storage and retrieval, specifically in the context of comparing current radiology studies to previous ones.


Real life example: Patient had a "routine chest x-ray" (ordered through his workplace; NOT me.) Report comes back:
Possible nodule left lower lobe. If comparison to previous films cannot be made [emphasis mine] then chest CT should be performed.
In my chart I have two previous chest x-ray reports (normal) from 2006 and 2004, performed at the same hospital -- NOT one with PACS. So once more, with great trepidation, I call and ask them to go ahead and compare the current study. Once more, at least with an apologetic tone this time, I'm asked to fax the request (and at least this time they don't lose it.) The next day I get an even more apologetic phone call: they found the patient's film jacket, but there were no films in it. (Reaction: somewhere between *WTF* and *sigh*) So he needs a CT of his chest.

As it happens, the patient's insurance requires him to go to a different facility for the CT than the hospital where his workplace-ordered (and paid for) "routine" chest x-rays were done. Although that hospital does not appear to have a full-fledged PACS up and running, they do provide the patient with an electronic copy of his film on a CD. He opened it on his computer at home, so he knows there's an image on the disk. Off he goes to the second facility -- the now proud purveyors of a brand-spanking new PACS system (meaning they presumably have computers and know how to use them) --for his CT and hands them the CD with his original chest x-ray image. The CT report:
Normal CT of the chest. No previous chest x-ray image available on our system.
Slow. Deep. Breaths.

Cut me a fucking break!! Lessons one, two, three and four in Radiology are about comparisons to previous studies. The whole idea of "portability" is central to the concept of continuity of care, and is something the fans of EHRs everywhere are claiming is their strongest point. Here's a guy with his film on a CD in his hand and no one can be bothered to point and click -- as he was able to do with commonly available software on his home computer -- and compare the goddamn images!

Until everyone gets their act together and agrees on some version of electronic formatting for both images and medical records (and then USES them) abso-fuckin-lutely NOTHING is going to change.

Thank you for your attention. We now return you to your regularly scheduled blogging.

UPDATE: I had the opportunity to go to the hospital recently and review some films in the department of Diagnostic Imaging. While there, I mentioned this case. The radiologist with whom I was speaking pulled it up and in fact found the chest x-ray from the other hospital. Apparently, the tech had copied it from the patient's CD into the system. He scrolled down and saw the name of the doc who had read it and commented, "She must not know how to pull it up. I'll have to go show her how to do it." So it turned out -- as it so often does -- to be a matter of people not using the technology to its fullest.


At Sat May 03, 02:37:00 PM, Anonymous Anonymous said...

Doesn't every hospital have good radiological facilities over there? It seems strange to me to send patients to different hospitals just for imaging... or is this just because of insurance company policies? that is fucked up.

At Sat May 03, 08:52:00 PM, Anonymous Anonymous said...

Tell me about it. Happens here all the time. Recently had a guy who was seen at a workplace "clinic" (actually an attempt by one of the local MDs to steal patients) and had an odd chest film. Same odd chest film he's had for 20 years. "Clinic" folks get panties in a wad, get the patient all in an uproar, want CT (which he had two years agao, just not at hospital "clinic" send their films to. Was able to resolve it because we have a radiologist who believe it or not, was actually willing to LOOK AT THE NEW FILM (on disc from other institution) and compare it with the old ones. At least occassionally the rad guys help us out....

At Sun May 04, 06:09:00 AM, Anonymous Anonymous said...

I once was admitting a patient from the ER who had an MRI done 2 days previously at a hospital 4 miles away. The neurologist wanted a new MRI stat so he could look at her tumor.

She worked for a cell phone company, and was flabbergasted that it was basically impossible for us to get the images that night, and the only reliable way to get them would be a family member acting as a courier in the morning.

She couldn't believe (and was a bit angry) that the technology surrounding the treatment of brain tumors was so behind the technology of picture messaging and custom ringtones.

At Sun May 04, 12:06:00 PM, Anonymous Anonymous said...

This is the kind of shit that wastes bazillions of dollars in our healthcare system. And the government thinks the solution is to cut reimbursements to doctors? We're the ones trying to prevent this crap!

At my last job, I would get x-ray report after x-ray report stating there was a nodule or whatever, compare to previous film or get a CT. It would take me 5 seconds to look on the computer and see if they had previously had an x-ray in our clinic. Then another 5-10 minutes or my time or my nurse's time to call and tell them they needed to pull the old one and have them compared. Then another 5 minutes of the radiologist's time to read it again (though serves them right not to DEMAND the old films the first time).

If the clerks/techs in x-ray had just pulled all the damn films the first time around, that would mean hours and hours of time saved a year.

What the hell? You'd think after I brought this up to their supervisors a couple of times the expectation would be made clear. This is the problem with having non-medical people supervising medical care--they don't actually understand the essentials in providing good medical care.

Wow, I could go on and on--guess I have already. Dino, I think you have the right idea running your own practice--I'm just too chicken...

At Mon May 05, 03:59:00 PM, Anonymous Anonymous said...

Sad but true, common sense is not common! Any system is only as good as the people using it it-


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