Creation and Storage of Standards-based Pre-scanning Patient Questionnaires in PACS as DICOM Objects
 
Authors:
Tracy J. Robinson, MD, Mercy Catholic Medical Center; Scott L. DuVall; Richard H. Wiggins, MD
 
Background:
A majority of radiology departments have now become filmless, with studies done via direct or indirect digital radiology systems and with interpretation done on Picture Archiving and Communications System (PACS) workstations. Filmless radiology has been shown to improve workflow, to increase patient throughput, and to provide more opportunity for real-time quality control[1-2]. Further, many institutions have successfully transitioned to becoming filmless in as little as 60 days[3]. In light of the benefits and successful transitions to filmless departments, some departments have gone one step further and addressed the goal of implementing paperless radiology as well. This has included not only speech-recognition, but also protocols, requisitions, and technologist sheets being scanned into the PACS or Radiology Information Systems (RIS), and this data associated with the selected study[4-7].

The trend toward paperless departments has seen similar benefits of efficiency[8]. To be complete, a transition to a truly paperless department should include the elimination of patient-associated paperwork, such as safety and consent forms and patient histories. Further, just as the Digital Imaging and Communications in Medicine (DICOM) standard revolutionized the filmless transition, incorporation of standards for medical information can enable effective decision support, enhance patient safety, and reduce overall costs of healthcare delivery[9]. We present a system that seamlessly integrates the paperless collection of required pre-scanning patient questionnaires into the practice of an outpatient clinic at an academic radiology department. In addition, by collecting the information in a structured and electronic format, we present how the patient information is mapped to the Systematized Nomenclature of Medicine – Clinical Terms (SNOMED-CT) terminology for maximal reuse and standardization.
 
Evaluation:
Currently, when a patient arrives for imaging in our institution, they are given paper forms associated with the type of study that will be performed, based on modality and the body part being imaged. The forms are used to obtain important clinical information required for accurate study interpretation, to identify safety hazards, and to rule out procedures that are contra-indicated. The forms become part of the patient file and must be included in the permanent record. Because of the large number of studies performed and the limit of on-site storage available, patient questionnaires are kept for a period of time, then moved to an off-site storage facility. When this happens, patients returning for follow-up imaging are often required to fill out new forms answering the same questions. Above being inconvenient, repeatedly filling out medical history without access to the original information can lead to inconsistencies or missed information, leading to incorrect interpretation of radiologic studies. We designed a system to replace the paper forms and store patient information along side the image study in PACS. This allows information related to previous studies to be recalled and modified when needed as easily as viewing previous study images. While the healthcare enterprise has been slow to adopt the use of standard terminologies, SNOMED-CT has been mandated and effectively used for the encoded collection of patient health information by numerous United States federal government panels, committees, and studies, as well as private institutions. SNOMED-CT has also become available free of charge for use in the United States through an agreement with the National Library of Medicine’s Unified Language System (ULMS).
 
Discussion:
We took the set of pre-scanning safety and patient history questionnaires used at our facility and converted them into web-based forms using PHP, JavaScript, and Cascading Style Sheets (CSS). Form information entered by patients are stored in a MySQL database where previously known information can be retrieved and preloaded into patient forms for subsequent studies. Patients arriving for an appointment at our outpatient facility are given a tablet PC that displays a set of instructions and walks the patient through only the questions required for the upcoming procedure, presenting relevant information entered from previous studies. Upon submission, all elements within the forms are systematically separated and mapped into concepts in the SNOMED-CT terminology. Not only can this information be used for auto-populating forms when the patient comes back for follow-up studies in the future, but due to the searchable nature of this standard terminology, the data can also be easily data mined for outcomes research and quality assurance. The standardized data elements are inserted into HTML templates to provide a consistent view for clinicians. Those documents then undergo a series of conversions from HTML, to PDF, to DICOM image objects using a commercially available server-side HTML to PDF converter and the Pixelmed Java toolkit. The forms are then transmitted to the PACS imaging database as DICOM objects to be included with and permanently stored as a separate series within the appropriate imaging study.
 
Conclusion:
This project demonstrates the process of capturing and converting patient questionnaires electronically that is integrated into the workflow and technologies currently used in the practice of radiology. Mapping patient questionnaire responses to the SNOMED-CT terminology and presenting the information in stylized HTML provides a consistent view of this information to clinicians and provides opportunities for the data to be reused for research and quality assurance. By transforming the form data into DICOM image objects and sending them for inclusion in the PACS imaging database, radiologists have ready access to the information directly through the PACS interface to support more accurate study interpretation. Patients no longer need to rely on memory alone in filling out forms they have filled out previously, and our department is one step closer to realizing the full benefit of becoming paperless.
 
References:
1. May GA, Deer DD, Dackiewicz D. Impact of digital radiography on clinical workflow. J Digit Imaging. May 2000;13(2 Suppl 1):76-78.
2. Dackiewicz D, Bergsneider C, Piraino D. Impact of digital radiography on clinical workflow and patient satisfaction. J Digit Imaging. May 2000;13(2 Suppl 1):200-201.
3. Hayt DB, Alexander S, Drakakis J, Berdebes N. Filmless in 60 days: the impact of picture archiving and communications systems within a large urban hospital. J Digit Imaging. June 2001;14(2):62-71.
4. Bassignani MJ, Dierolf DA, Roberts DL, Lee S. Paperless Protocoling of CT and MRI Requests at an Outpatient Imaging Center. J Digit Imaging. 2008 Nov 22. [Epub ahead of print]
5. Bedel V. The strategy to be "paperless" via a cost-effective filmless plan. J Digit Imaging. 2002;15(Suppl 1):15-19.
6. Halsted MJ, Froehle CM. Design, implementation, and assessment of a radiology workflow management system. AJR Am J Roentgenol. 2008 August;191(2):321-7.
7. Warfel TE, Chang PJ. Integrating dictation with PACS to eliminate paper. J Digit Imaging. March 2004;17(1):37-44.
8. Ralston MD, Coleman RM, Beaulieu DM, Scrutchfield K, Perkins T. Progress toward paperless radiology in the digital environment: planning, implementation, and benefits. J Digit Imaging. June 2004;17(2):134-43. Epub 2004 Apr 19.
9. Donnelly K. SNOMED-CT: The advanced terminology and coding system for eHealth. Stud Health Technol Inform. 2006;121:279-90.