Bone Density Imaging Workflow

In this post, we’ll describe medical imaging workflow as it specifically applies to DXA based bone densitometry.  Radiology departments, imaging centers, and hospitals have implemented efficient processes that maximize the volume of patients, along with revenue, and also minimize errors.

This posting assumes modern technology is in place, such as electronic medical records (EMRs), hospital information systems (HIS), radiology information systems (RIS), DICOM for electronic image transfer, and picture archiving systems (PACS).  For a reporting system, we’ll assume BoneStation is used.  We’ll also assume the EMR, HIS, or RIS provide order entry and results capabilities (where ordering providers view test results).

The following diagram depicts typical workflow, but adapted for DXA based bone densitometry.  The workflow can be thought of as an assembly line, where the patients navigate through the process.  Often times, patient flow may be tracked throughout the day via the EMR/RIS/HIS.

1) An order is placed (scheduled) for a bone density test.  Often times the ordering provider calls the bone density practice to order a test.   The order is entered into the EMR/RIS/HIS.

2) Patient arrives for the exam on the scheduled day.

The receptionist may log into the EMR/RIS/HIS and update a patient’s status to “arrived”.

3) A DXA technologist scans the patient on the bone densitometer, analyzes the scans in the DXA software, and transmits the scans, via DICOM, to BoneStation.  BoneStation extracts all the quantitative data and the images.

If DICOM Modality Worklist (MWL) is available on the DXA, the tech may pull all the patient info (name, DOB, ethnicity, etc) electronically from the EMR/RIS/HIS into the DXA software.  Otherwise the technologist manually enters patient demographics.

The technologist logs on to BoneStation and fills in the patient history questionnaire.  FRAX is built into BoneStation, and the questionnaire is filled out there instead of in the DXA software.  There are advantages to having questionnaires in BoneStation, which are discussed here.

The technologist may update the patient’s status in the EMR to “complete”.

4) A physician, that is specially trained to read DXA scans, logs into BoneStation and reads the bone density scans.  BoneStation automates much of the process of reading scans.  The final output is a bone density report.  This video demonstrates how easily and quickly reading scans is in BoneStation.

5) BoneStation distributes the report to the EMR/RIS/HIS.  BoneStation creates fully formatted reports, with tables, images, and charts.  Click here to see some sample reports.  Depending on the interface between BoneStation and the EMR, only a text report may be available or the fully formatted report in the EMR.

BoneStation supports a variety of ways to distribute reports, including printing and faxing.  This article provides more info about one instance of a BoneStation to Epic interface.

Once the EMR receives the bone density report, the patient’s status is updated to “final”.  This may also trigger events related to billing.  The process for the patient’s scan is now complete.

6) The ordering provider accesses the report in the EMR/RIS/HIS.  Some EMRs may notify the ordering provider that results have been received when the report is received by the EMR/RIS/HIS.

The workflow described here is typical for most hospitals, radiology departments and imaging centers.  There are some unique aspects that are specific to DXA. We will go into more detail regarding DXA in a future posting.

Three Keys to Quality Bone Density Reporting

This posting is the last of a 3-part series about bone density reporting and how BoneStation can make a difference compared to common practices. Part 1 focused on costs reduction and part 2 on time savings.  In this article we discuss three specific areas that BoneStation addresses in regards to quality:

  • The Report – components that comprise a good bone density report
  • Review process – facilitating a sound interpretation
  • Workflow – improving communications between staff

The Report
The International Society for Clinical Densitometry defines the minimum requirements for a bone density report.  Some items that should appear on a report include: patient demographics, BMD values for each site measured, DXA manufacturer/model, and significant change.

BoneStation automates report creation.  Manual data entry is eliminated.  BoneStation extracts all appropriate DXA data and places the data in a report.  In addition, changes in BMD and determination of significant change are automated.  A final bone density assessment is even suggested.

The Review Process
While DXA bone density scan images should not be used for diagnostic purposes, they are instrumental in determining the consistency of serial measurements.  Is the patient positioned properly?  Are the regions of interest (ROIs) consistent with prior scans?  What is the technical quality of the scans?

BoneStation’s review process is designed to highlight key aspects for interpretation.  Prior scans are easily visible. ROIs may be viewed both visually and numerically.  Technical quality of scans must be specified and may also appear on the report.

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Workflow
In most situations, the technologist and reading physicians are in different locations.  Scans are not typically read in real time either.  Improved communications among bone density staff can lead to increased quality.

  • BoneStation allows technologists to pass information to reading physicians via “scan comments”, which are entered on the DXA and appear in BoneStation.
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  • BoneStation may be configured to “validate” patient information for consistency.  Is data missing, is patient demographic info consistent, etc.  For example, if a female patient is 62 years old and is designated as pre-menopausal, BoneStation is able to provide a warning that this information may not be valid.
  • When a reanalysis is required, BoneStation facilitates communications between the reading physician and technologist.  The reason for reanalysis is described to the technologist.  The scan is also tracked as awaiting reanalysis – so staff will not lose track of it.
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Summary
BoneStation is designed specifically for DXA based bone densitometry.  It increases efficiency and quality simultaneously.  Much of the mundane handling of bone density scans is automated. It facilitates a review process designed for bone density, and enables easy communication among bone density staff.

BoneStation has produced more than a half million reports and has proven to be reliable solution for BMD reporting.  Customers such as Mass General Hospital, Swedish Medical Group, Emory and others enjoy higher throughput and quality at lower cost.

Speedy Bone Density Reporting with BoneStation

This posting is part 2 of a 3-part series highlighting how BoneStation can reduce costs, save time, and improve quality in BMD reporting.  In the previous blog, we emphasized the cost savings aspect. Here we focus on the time aspect, or the speed of reporting.

Bone Densitometry using DXA has been around for a while. As we all know, a particularity of BMD scans is that they output images (spine, hip, etc) as well as numerical values (BMD, BMC, T-score, Z-score, etc…).

In today’s digital world, still many practices waste precious time in error-prone manual steps when reviewing DXA studies. These steps include: writing down numbers on paper, calculating BMD changes with calculator, retrieving historical scans from PACS, using post-its to ask technologists for reanalysis of a scan, using dictation, using the FRAX website, etc…

BoneStation resolves these issues, thereby offering the opportunity to save time at several points of the workflow:

  • Data (BMD, T-score, etc..) is extracted directly and instantaneously from the DXA scans
  • No need for human reading, dictation or transcription
  • Current and prior scans (images and numbers) show up side by side allowing for instantaneous comparisons
    • no need to pull charts, or to retrieve historical images and data on PACS
  • BMD changes are computed instantaneously and show up in the report
  • BMD changes are instantaneously compared to the stored least significant changes
  • FRAX is calculated automatically according to ISCD recommendations
  • Request for reanalysis is built in BoneStation for quick and traceable communication with the technologist

Even today we occasionally observe situations where readers do not compare scans with priors and do not calculate changes in BMD.  The International Society of Clinical Densitometry (ISCD) recommends these as important elements of a bone density report.  Perhaps it takes too long to provide this information in a report.  However, BoneStation makes it easy.

This BoneStation video illustrates how quickly a reading physician can review a spine and hip DXA study, including FRAX.  An actual review, with prior scans, can often take under one minute with BoneStation.  With the narrative in the accompanying video, it takes about a minute and half to review a spine/hip.

We hope that this brief blog helps you think through your bone densitometry process. 

Sylvie Bokshorn

BoneStation has produced more than a quarter million reports and has proven to be reliable solution for BMD reporting.  Customers such as MGH, Swedish Medical Group, Emory and others enjoy higher throughput and quality at lower cost.

How a Large Hospital Reduced the COST of Bone Density Reports by 60%

This posting is part 1 of a 3-part series describing BoneStation and how it can ease the burden by reducing costs, saving time, and improving reporting quality.  Here we focus on cost reduction, while keeping in mind that time, money and quality are connected.

Of course, cost savings will depend on your practice. In this blog, we bring your attention to the case study done by Dr. Rosen at Beth Israel Deaconess Medical Center, where the cost per report were reduced by 60%.

Bone Densitometry practices operate under increasing pressure to perform with less. Challenges abound, including overloaded staff, complex workflows, reporting errors, and of course low DXA reimbursement.

Performing precise and accurate DXA measurements takes effort.  DXA machines are sensitive devices requiring correct calibration and patient positioning. Capturing patient history properly and providing consistently quality reports demand much energy and focus. Let’s not forget that DXA stands out as an imaging modality (compared to regular X-Ray, MRI, or Ultrasound) because the output consists of images and numerical values.

The cost savings, in the case of Dr. Rosen, came from:

  • Reduced labor cost:
    • no need to pull charts because BoneStation provides all prior scans during review.  Both the prior scan images and numbers are available.
    • no need to dictate and transcribe
  • Cost savings due to space savings – Paper storage of charts no longer needed because all scans (images & date) are stored electronically in BoneStation.  
  • Cost savings in materials, such as ink and paper, because no need to print reports.  Reading physicians have access to all scans (image & data) in BoneStation.
  • Time is money: reading physicians interpret scans faster because current and prior scans show up side by side during review (no extra step or click needed).
  • Subtle yet important costs are those associated with errors in reporting numerical values such as the T-scores. Such costs can impact the entire hospital. BoneStation eliminates such errors since the values are directly extracted from the DXA software.

Even though we focused on the economic aspect, we must highlight a powerful triple outcome resulting from the ability in BoneStation to observe prior scans and current scans side by side: it not only saves money, and time, but also increases quality. The fact is that still today, many readers do not take the time to check prior scan images and numbers, even though this is important in order to check for consistent patient positioning and analysis.

We hope this short blog helps you as you assess or reassess your current bone densitometry process. We invite you to learn more by clicking here: case study by Dr. Harold Rosen of BIDMC.

Sylvie Bokshorn

BoneStation has produced more than a quarter million reports and has proven to be reliable solution for BMD reporting.  Customers such as MGH, Swedish Medical Group, Emory and others enjoy higher throughput at lower costs.

BoneStation: a summary of advantages

We have been asked recently to present a summary of advantages that BoneStation provides to users. In this blog we first list what we believe are the key advantages our reporting solution brings compared to traditional methods. We then refer the reader to the results of a mini survey we sent to our current power users.

Differences and advantages that we believe BoneStation brings versus traditional reviewing, interpreting, and reporting methods for Bone Density Testing:

  • faster review
  • possibility to view current scan (image & data) and prior scan simultaneously
  • no data errors (no manual entry, no paper, no dictation)
  • possibility to review scans from anywhere (with web access)
  • more efficient workflow
  • faster overall turn-around
  • more efficient storage of the reports (patient exam, and questionnaire and report stored electronically and linked to each other)
  • possibility to interface to EMR
  • ability to do queries (data is structured in database)
  • better-looking reports
  • calculations of BMD changes and FRAX according to ISCD recommendations
  • possibility to scale up & standardize across several DXA machines (because use of centralized database)
  • possibility to customize your patient questionnaire.

We sent out a subset of ten of these points to our current power users (mostly physicians, and a few technologists) and ask them to pick the 3 most important benefits to their practice.

The results are: 1. the availability of prior scan images during review. 2. the possibility to review exams from anywhere. 3. better workflow compared

You can find the full ranking here:  BoneStation Survey

 

Reviewing DXA Scans on the Web with BoneStation

BoneStation is a web-based reporting solution which increases the productivity of bone density testing providers, including technologists, physicians, and administrators. In this article we focus on physicians who are responsible for the review and interpretation of BMD and VFA scans.  The physician will essentially do the following: select the exam to review, assess the technical quality of each scan, and  generate the report by filling in the various components (Assessment, Recommendations, Fracture Risk, etc). We describe that process in further details below.

The Review List and Initiating the Review Process

The physician starts by looking at The Review List, a list of recently performed BMD scans which need to be read.

BoneStation Review List

Review List shows scans awaiting review. (click for full size)

 

 

In this case the system shows 29 exams ready to be reviewed. Notice the drop down menus at the top.  These are particularly useful in situations where there are multiple DXA machines and multiple reviewers.  The Exam Date filters the list to show scans performed on a particular day.  The Location filters the list based on the DXA machine’s geographic location.  The list can also be sorted by Patient, Exam Date, and Referring Physician. In this Review Step 1, the physician  initiates the review process by clicking on Create Report (left button).

Selecting the relevant historical scans

Review Step 2 appears as “Select Comparison Scans”. During this step the current PA spine scan and all historical PA spine scans are displayed in summary fashion.  Prior scans that the physician does not want included can be excluded from the report by clicking the Exclude checkbox.

On Review Step 2 prior scans may be excluded.  (click for full size)

On Review Step 2 prior scans may be excluded. (click for full size)

 

 

The screen shows a summary of each prior scan, including scan date, scan mode, serial number of DXA machine, analysis date, and relevant BMD data.  If a prior scan was performed on a different DXA or using a different scan mode, the corresponding data would be highlighted in red.  This alerts the reviewer to the fact that he may want to exclude the scan.  For example:

Scan mode differs and is highlighted.

 

 

 

 

 

 

 

 

 

Looking back at Review Step 2, notice that “OK” appears in the Tech Quality column for the 11/10/2011 scan.  The 2011 scan has a report that was created in BoneStation and its technical quality was evaluated to be OK at the time of review.  Clicking OK pops up that report for immediate viewing.

Assessing Scan Quality

Click the Continue button to move to the next step.  On Review Step 3 one can compare the images of the current scan and the baseline.  Additional images, with scan data, may be viewed by clicking the dates in the Other Historical Scans section.

Specify scan quality

Review Step 3

On Review Step 3 the reviewer indicates the technical quality of the scan as either OK, marginal, or uninterpretable.  When one of the latter two is selected, one or more reasons must be picked in the second column.  If a scan is designated as uninterpretable, it will not be used in the final assessment. It is also during this step that a reviewer may request for a scan to be reanalyzed.  In this case the physician reviewer is prompted to send instructions to the technologist via email.  The scans are retained in BoneStation in a separate “Awaiting Reanalysis” queue.

Summarizing the Report

Clicking the Go To Next Scan button repeats this process for the remaining scans.  When the final scan is viewed, the Go To Next Scan button changes to Add Recommendations.  At this point the content of the various report sections are filled in.

Recommendations

Report sections are filled in, some automatically. (click for full size)

 The Summary screen can show a variety of optional report sections.  In the above example:

  • The Comparison To Prior Studies section gives a verbal description of change.
  • The Assessment section gives the interpretation.
  • The Current and Past Treatments section lists treatments as entered on the electronic questionnaire.  We did not discuss the questionnaire much during this article.  Note that it is available throughout the review process via the Questionnaire link.
  • Next visit is the suggested followup.
  • FRAX Results is the fracture score.  In the above example a FRAX score was not calculated because the patient is osteopenic.
  • Comments provides for general comments.

Note that there are drop down menus with many sections.  These contains macros of frequently used phrases that may be easily entered in to the report. The physician can also manually enter information into any section.

In Summary

This was a brief overview of the review process.  Many features, such as the integration into EMR systems, were not described or were only touched upon to keep the article short. If you would like to learn more, feel free to contact us.  Of course we are happy to hear from you if you have specific topics you’d like covered in future articles. Thank you.

Can “The Cloud” help with financial pressures on DXA?

DXA bone density testing has been experiencing mounting economic pressures, as has most of healthcare.  Reimbursement cuts have reduced revenue to bone density providers and bone density test volume has at best remained flat.  As a result, DXA operators have had to become more efficient.

The Cloud” has been instrumental in other industries, including government and military, in reducing costs.  Can “The Cloud” help DXA practices similarly?

Cloud-based applications are typically offered on a Software-As-A-Service (SaaS) basis.  The idea behind SaaS is simple: pay for what you use.  The implication is that the initial purchase of software, which can be quite costly, is replaced with a subscription-type model.  The subscription can be based on any number of factors, such as per user, amount of storage, or simply usage.

There are other savings too:

  • SaaS applications typically minimize – or even eliminate – the need for an internal IT department.  There is no on-site hardware or servers and thus no maintenance for those items.  Installation is easy – often times simply requiring a web browser.
  • SaaS applications often time include upgrades and support.  The traditional model for purchasing software involved an initial purchase and occasional upgrades, that had to be purchased.
  • SaaS services are often scalable.  A business can start small and easily add capacity as it grows.

In future articles we will discuss more advantages of the SaaS model.