GUIDE TO IMPLEMENTING ORDERCOMMS IN RADIOLOGY

There are 4 Clinical IT systems that are involved in Electronic Requesting in Radiology

1.  Ordercomms

2.  RIS

3.  PAS

4.  PACS

An organization may choose to buy modules from a single supplier or a different supplier for each element. Irrespective of what is chosen, the Integration requirements need to be clearly defined for a successful implementation.

A.  Ordercomms Data Fields Population for Radiology

There are 4 methods of populating data fields on Ordercomms

a.  Automatic population from PAS,

b.  choose from a list

c.  free text entry

d.  Automatic population from log-in details/system

The following data fields in to be populated & the information in brackets indicates best method of data population.

1.  Name (synchronised with PAS)

2.  DOB(synchronised with PAS)

3.  Sex (synchronised with PAS)

4.  PAS No. (synchronised with PAS)

5.  NHS No. (synchronised with PAS)

6.  Requesting Responsible Consultant/GP (automatic population from PAS—Responsible Consultant at Request—but can be changed by user if required)

7.  Requesting Speciality/Department (Automatic population from PAS—based on what is chosen for point 6 above)

8.  Requesting Doctor (who maybe a junior doctor)---(Automatic population from log-in details)

9.  Contact number for Requesting Doctor (Automatic population from log-in details)

10.  Patient Location at Request (automatic population from PAS—Patient Location at Request but can be changed by user)

11.  Date of Request (automatic population from system)

12.  Priority---Urgent Routine etc (Choose from a list)

13.  Patient Category---NHS, Private, CatII etc (Choose from a list---default to NHS)

14.  Exam Description---(choose from list)

15.  Clinical History---Free text entry

16.  Exam/Location/Gender specific Questions/Alerts (See Section H)

B.  Ordercomms Data Fields that MUST be transmitted to RIS automatically:

  1. Name (synchronised with PAS)
  2. DOB(synchronised with PAS)
  3. Sex (synchronised with PAS)
  4. PAS No. (synchronised with PAS)
  5. NHS No. (synchronised with PAS)
  6. Requesting Responsible Consultant/GP
  7. Requesting Speciality/Department
  8. Requesting Doctor
  9. Contact number for Requesting Doctor
  10. Patient Location at Request
  11. Date of Request
  12. Priority
  13. Patient Category
  14. Exam Description
  15. Clinical History
  16. Exam specific questions (See Section H)

C.  Real time Exam Status Synchronization

It is very important for a rich integration that all 3 systems--(Ordercomms, RIS & PACS)—are synchronised for the exam status:

1.  Requested (ORDERCOMMS)

2.  Request Vetted (RIS)

3.  Request held/deferred—with reason (RIS)

4.  Scheduled or appointment given (RIS)

5.  Cancelled (RIS/ORDERCOMMS) with reason

6.  Arrived/Attended (RIS)

7.  Did Not Attend (RIS)

8.  Exam performed (RIS)

9.  Exam not performed—with reason (RIS)

10.  Report Dictated (RIS)

11.  Unauthorised report (RIS)

12.  Authorised/Verified Report(RIS)

13.  Amended Report (RIS)

14.  Report acknowledged (ORDERCOMMS/RAS)

15.  Review requested (Ordercomms)

D. Change and Cancel requests on Ordercomms

Status synchronization between Ordercomms & RIS is key here.

An Ordercomms system SHOULD ONLY ALLOW a user to cancel or change a request at the “REQUESTED” status (because until then the radiology department has not dealt with the request).
Once the RIS has taken the request and dealt with it with a status change to—“vetted”, held, “scheduled/appointment given”, “patient arrived/attended”—the Ordercomms SHOULD NOT allow a clinical user to cancel or Change a request. The following message should come up on the Ordercomms system---“this request is now with the radiology department---if you wish to change or cancel please ring extn----“.

E. Change and Cancel requests on RIS

At vetting stage or later an order maybe cancelled on RIS. Through status synchronization the status in Ordercomms & RIS to cancelled. The reason for changing or cancelling the Request is documented in RIS. This must populate the results field on Ordercomms. This will allow for appropriate communication to referring teams.

F. Patient Location on Ordercomms:

It is important that the department understands that with electronic systems like Ordercomms term “location” is clearly understood on all the systems, OCS, RIS, PACS and PAS.

1.  Patient Location at the time of Request. This is what is currently recorded on paper systems. This is where the reports currently goes to (as the responsible consultant for that request is at that location—and is responsible for reading the report). With Ordercomms deployment, paper requesting will continue for some time in tandem. Hence, it is important that consistency is maintained for both processes. This location is currently manually entered into RIS. It is important that when integration work is done, that the HL7 message populated into RIS from Ordercomms, is actually the “Patient Location at the time of Request”.

2.  Current Patient Location: This is generally updated on an ADT (admission Discharge Transfer) system--- in the UK this is the PAS system. It is possible that a request for a scan is made when the patient was an inpatient, but at the time of appointment or reporting the patient maybe admitted to hospital as an emergency. Hence, it is important that staff in the department are aware of the current patient location to arrange porters/convey any critical report.(Please see E).

3.  PC Location: Some Ordercomms may actually record PC location instead of patient location---as “location”. This is particularly of value for use of shared printers where request card/sample labels for pathology are being printed out. It is important to understand that PC location may not be synonymous with Patient location. Current paper based processes deal with “Patient Location at request” not requesting doctor’s location or PC location.

G. CONSISTENT CLINICAL USER INTERFACE

Vital Patient Information Display on RIS, OCS and PACS

RIS, PACS and Ordercomms MUST display clearly and consistently the following.

  1. Patient Demographics (Name, DOB, Sex, PAS No., NHS No.)
  2. Current Patient Location
  3. Current Responsible Consultant
  4. Current Speciality or Department
  5. Requesting Responsible Consultant

(The difference from Requesting vs. Current Responsible Consultant & Requesting vs. Current Patient location must be understood)

From a patient safety perspective it is recommended that the above 4 items are displayed on the top demographics bar of all systems. The above ( 1 to 4) MUST have real-time synchronization with PAS, so that it is always up-to-date.

a.  This will allow critical patient related information to be communicated with the correct team/doctor who is responsible for the patient by other departments.

b.  It also allows the departmental staff to know where patients are when an appointment has been made for them.

H. Electronic Request Information Display on RIS

RIS must be able to display this information in a clearly which is easy to read by radiologists

1.  Clinical History

2.  Exam Description

3.  Priority

4.  Requesting Responsible Consultant/GP

5.  Requesting Speciality/Department

6.  Requesting Doctor (who maybe a junior doctor)

7.  Contact Number of Requesting Doctor

8.  Patient Location at Request

9.  Patient Category

10.  Date of Request

11.  Output from Specific Questions based on exam type/location etc asked on Ordercomms (See Section I):

I. Exam/Location Specific Questions should be configurable for local needs. Some examples are:

I. “Read by Referrer" Exams—For example plain X-ray requests for limbs post fracture manipulation, fluoroscopy images in theatre, OPT etc. (not for Chest/abdo/spine plain x-rays) will have the following question:

1.  Report Required (Radiology)

Is a report required? Yes or no

II.  Female and of child bearing age (for relevant exams only-All CT, MRI, Fluroscopy, some plain X-rays, NM etc):

1.  Pregnancy (Radiology)

Is the patient pregnant? Yes or No.

If yes, EDD--- . For MRI exams the following message will appear: Please discuss the need for MRI with a radiologist.

III. Inpatient/A&E Examinations

a.  Infection (Radiology)

Does the patient suffer from infections which require barrier nursing: No, C.Diff, MRSA,

b.  Mobility (Radiology)

Mobility---Chair/bed/trolley/Portable(if poss)

IV. Outpatient Examinations

a.  Transport (Radiology)

Transport---Own transport, Medicar, Ambulance

V.  Questions for Exams Requiring Iodinated IV Contrast (CT with contrast, Angio, IVU, etc):

1.  Contrast Induced Nephropathy Risk Assessment (Radiology)

“The last Creatinine level was ----- on --/--/--“ (This will be automatically displayed from the results/pathology system)

Contrast Induced Nephropathy Risk Assessment based on recent Creatinine Levels (link to local guidelines)

RCR Guidelines on IV contrast use: https://www.rcr.ac.uk/docs/radiology/pdf/BFCR(10)4_Stand_contrast.pdf

Options to choose from:

  1. Low risk (Creatinine <130)---Peri-procedural oral fluid hydration advised. Patient Informed.
  2. High Risk (Creatinine >130)---Need for IV contrast administration needs to be reassessed (e.g. Would a non-contrast exam suffice? Is an alternative investigation possible?) If IV contrast exam is deemed necessary, then peri-procedural IV fluids hydration as per guidelines needs to be organised by the referring team.
  3. Not relevant—as patient is on dialysis
  4. Up-to-date Creatinine levels requested

2.  Diabetes (Radiology)--- (Iodinated contrast exams only –not MRI)

Is the patient Diabetic? Yes or No

  1. If Yes---Is the patient on ----Diet control, Insulin, Metformin or medication other than Metformin?
  2. If on Metformin---Please read the RCR advice re: Metformin and IV contrast.

RCR advice on IV contrast use:

https://www.rcr.ac.uk/docs/radiology/pdf/BFCR(10)4_Stand_contrast.pdf

a. If the serum Creatinine is normal, no special precaution is required.

b. If Serum Creatinine is abnormal then the need for IV contrast should be reassessed ((e.g. Would a non-contrast exam suffice? Is an alternative investigation possible?). If IV contrast is deemed necessary, discussions with a Diabetologist is required before stopping Metformin.

VI. Questions for MRI Exams

1. Absolute contraindications to MRI (Radiology)

Does the patient have any electro-magnetic implants (which are MRI Hazards) such as:

Cardiac Pacemaker

Cardiac Defibrillator Implant

Cochlear Implants

Brain/Nerve/Bladder Stimulator etc

Answer: Yes, No, Patient not present

If answer is Yes:

Patient cannot have an MRI scan. Please discuss with radiologist regarding alternative test.

2. Possible Contraindication to MRI-- Safety Assessment Required (Radiology)

Does the patient have any possible contraindications to MRI---

Intracranial aneurysmal clips

Retained shrapnel

Metallic Prosthesis

Spinal rods

Heart surgery

Spinal surgery

Brain Surgery

Recent surgery

Shunts/vascular stents/vascular clips

Others

Answer: Yes, No, Patient not present.

If answer is yes : Please provide details with date and type of procedure/implant. MRI staff will do a safety assessment prior to MRI.

3. Metallic Intraorbital Foreign Body (MRI hazard) (Radiology)

Does the patient have a any history of a metallicIntraorbital foreign body (Please take relevant occupational history—welder etc)?

Answer: Yes, No, Patient not present

If answer is Yes? MRI will pursue with patient to ensure safety as per Intraorbital Foreign Body Policy for MRI.

4. Claustrophobia (Radiology)

Is the patient claustrophobic? Yes, No, Patient not present

a. If yes, Do you think patient will require oral sedation or GA (they will need to choose 1 of the options).

i.  If they choose Oral Sedation then message will appear: MRI department will discuss with patient and organise for oral sedation.

  1. If they choose GA then a message will appear: Please take relevant medical history and refer to Anaesthetic Dept for assessment."

5. MRI Safety Questionnaire Reminder (Radiology): Please ensure that the patient fills in and signs the MRI safety questionnaire. If the patient is unable to fill in/sign off a safety questionnaire, it is the responsibility of the referring doctor to sign it on behalf of the patient.

6. Patient Girth & MRI (Radiology) (This will appear forall examinations)Please ensure that thepatients maximum body circumferencedoes not exceed 170cms otherwise the patient will not fit in the MRI scanner

7. Exam Specific Girth & MRI (Radiology) This will appear for certain exams like cervical spine/neck etc).

Please ensure that the(body part requested - neck, knee, abdomenetc ) circumferencedoes not exceed (measurement in cms ) otherwise the patient will not fit in the MRI (coil type e.g neck/ knee/ body phased array)coil.

Max neck circumference = 45cm

Max knee circumference = 60cms

Max circumference for chest, pelvis, liver, MRCP, abdomen = 150cm

8. MRI Contrast (Gadolinium) (This will appear forall examinations that require Gadolinium)

“The last Creatinine level was ----- on --/--/--“ (This will be automatically displayed from the results/pathology system)

Please read Royal College of Radiologist guidance https://www.rcr.ac.uk/docs/radiology/pdf/BFCR(10)4_Stand_contrast.pdf

on use of Gadolinium in patients who:

a.  Have impaired renal functions

b.  Are peri-operative liver transplant

c.  Are pregnant

d.  Breast Feeding

VII.  Alert for exams requiring Bowel Prep (barium enema etc)

Bowel Prep Alert (Radiology):

NB: Please ensure that the patient can tolerate bowel prep. Guidelines link.

VIII.  Reminder for exams needing consent form:

Consent Form Reminder (Radiology)

NB: Please complete a consent form for this exam.

IX. For any same exam requested within the last 6 months the following message will pop-up.

Repeat Exam Alert (Radiology):

This exam was performed on DD/MM/YYYY"

However, this should not prevent a further request being made, and should not require extra mouse clicks.

X.  All exams:

Royal College of Radiologists Guidance (Radiology):

Making best use of Radiology Services http://mbur.nhs.uk/index.asp

J. LINK TO DECISION SUPPORT FROM ROYAL COLLEGE OF RADIOLOGISTS: At every stage of requesting, the Ordercomms system should provide the url link to RCR decision support—“Making Best Use of Radiology Services”

http://mbur.nhs.uk/index.asp

K. Consistency in Naming of Data Fields—

There should be consistency in naming of the following data fields in Ordercomms, RIS, PAS & PACS (in fact in all Clinical IT systems). This would avoid ambiguity and confusion for the user community.

1. Requester

2. Grade of Requester

3. Requesting Responsible Consultant/GP

4. Current Responsible Consultant/GP

5. Patient Location at Request

6. Current Patient Location

7. Date of Request

8. Date of Exam*

9. Date of Report

10. Patient Category

11. Exam Description*

12. Exam Status*

13. Author of Report

14. Grade of Author

15. Clinical History

16. Patient Location Types (Inpatient, Outpatients, GP)

17. Requesting Department

18. Reporting Department

19. Priority

*Where there is a overlap of data field use in radiology & pathology—the term “Investigation” maybe more appropriate rather than “Exam”.

L. CONTEXT LINK: ORDERCOMMS, RIS & PACS:

1. RIS to Ordercomms: There should be a context link from RIS to Ordercomms, which will allow radiology staff to open Ordercomms to the relevant patient through a button/icon on the top tool bar of RIS.