Workflow orchestration aims to bring together radiologists at different institutions in a health system, ensuring that imaging studies are read quickly and by the most appropriate radiologist for the case. It can be implemented using traditional imaging informatics systems or the electronic medical record (EMR), or by purchasing dedicated software, said Dr. David Hirschorn, chief of informatics, imaging services, at Northwell Health.
A workflow orchestrator could, for example, help balance radiologist workload, prioritize urgent studies, and minimize turnaround time.
"It is not easy to transition from 'dumb' worklists to a workflow orchestrator, but it is well worth it long-term in a large healthcare system," he said.
Why workflow orchestration?
Consolidation has been the healthcare trend over the past 10 years, and smaller hospitals continue to get acquired by larger healthcare systems. These healthcare systems are much more complex than the sum of their parts, according to Hirschorn.
"It's just impossible to effectively and efficiently manage a large group of radiologists and technologists without [workflow orchestration]," he said. "Lists based on modality and anatomy just ain't enough anymore. It's not going to work in today's healthcare environment."
But Hirschorn noted that expectations need to be set to get radiologists to do their work effectively.
"A good workflow orchestrator makes sure the work gets done fairly and efficiently," he said. "It minimizes the gaps and avoids slowdowns in turnaround time."
Workflow orchestration can ensure access to modality expertise, subspecialty expertise, and even sub-subspecialty expertise. For example, a radiologist may have specific expertise in reading MR pelvis exams for the prostate or chest CT scans for lung cancer screening or interstitial lung disease, Hirschorn said. Load balancing among the various sites in the health system is also an important goal.
In addition, workflow orchestration aims to enhance throughput and minimize turnaround time. This includes a focus on prioritizing urgent studies such as stroke exams, having faster reads overall, and meeting requirements of service-level agreements, Hirschorn said.
Another goal is to assign interventional procedures to the performing radiologist for dictation, and to ensure -- via alerts and administrative worklists -- that no imaging study goes unread for too long. A real-time dashboard can provide a view of unread studies; it's also beneficial to show imaging studies that are currently in progress.
Workflow orchestration can facilitate communication between radiologists and technologists and schedulers, and one advanced goal is normalization of imaging exam descriptions across the enterprise, he said.
"A workflow orchestrator is kind of something that's filling in for all of the things that your RIS never did and can't do; it's just beyond it," Hirschorn said. "If the RIS was the hub that fed your PACS, dictation system, and any other system that you have ... this is something that can be added on to a RIS and let everything hang off of that because it can do this exam description normalization. If you have a RIS that can do it, great; I just haven't seen one."
Other advanced goals for a workflow orchestrator include assigning imaging protocols, dynamic load balancing (reassigning work as necessary based on available radiologist resources), and critical test results management. Optional goals include utilizing quality assurance (QA) tools and handling document management, he said.
Getting a workflow orchestrator
Workflow orchestration can be implemented in a number of ways, including by leveraging the familiar three major information systems in radiology: the RIS, PACS, and dictation system. Any of these systems can provide a worklist.
"The problem is, it's just not their core competency," he said. "When you look at all of the things you can do [with workflow orchestration], it's not just typically what these systems see themselves as in the business of accomplishing."
Other options include utilizing the electronic medical record. This can work because it minimizes the need for interfaces, Hirschorn said.
An independent workflow orchestrator can also be purchased from a vendor, an approach that Hirschorn recommends because such software focuses specifically on organizing workflow.
"These other systems ... it's just not their primary focus," he said.
At Northwell Health, the workflow orchestrator integrates with two different diagnostic viewers, the dictation system, QA tools, the health system's internal health information exchange (HIE) system, and the physician scheduling system, for example.
The integration with the dictation system, possibly multiple PACS, the radiologist shift schedule, QA tools, and, crucially, the EMR is what makes a workflow orchestrator more than just a worklist, Hirschorn said. Integration with the EMR is transformational for the radiologist.
"Finally we can go back to the skills that we learned in medical school to understand how to read a patient's clinical history, their problem list, the medication list, the working diagnoses, labs, allergies, and surgical history," he said. "We can be doctors again. We can actually practice medicine by being aware of the same information that all of the other doctors are aware of about the patient."
In deciding on a workflow orchestrator, Hirschorn recommends looking at the health system's goals and then picking the product that best suits your needs. Healthcare systems will also need to decide whether to implement a workflow orchestrator all at once or site by site. He noted, however, that it's difficult to have two worklist systems running concurrently.
Among the challenges of implementing workflow orchestration is the need to switch workstation integrations from the old model to the new workflow.
"The workflow orchestrator is driving the desktop now instead of the PACS driving it," he said.
It's hard to anticipate the needs of each division, so it's helpful to sit down with them to go over what the worklists will look like. It's also difficult to measure large-scale performance until you try it with hundreds of users at the same time, Hirschorn said.
In addition, real-time integrations can slow things down if you let them, and it's difficult to support multiple sites going live simultaneously, he said.
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