By law, each time changes are made to patient scan protocols they must be accompanied by a new order from the referring physician. In order to maintain policy, laws and procedures, a great deal of paper documentation is still used throughout radiology practice. Progress towards paperless radiology in the new age of digital environments can be an up-hill battle, especially for outpatient imaging centers.

Though still representing the depth and complexity of illnesses seen within a tertiary care environment, outpatients being scanned away from the overwhelming hustle and bustle of inpatient imaging suites no longer encounter delays due to 'emergency add-ons'. Instead they are greeted by new facilities, expertly trained technologists, and state-of-the-art imaging equipment. However, the management and protocoling of received orders have proven to be a laborious process.

Dr. Matthew Bassignani, Assistant Professor of Radiology and Director for Radiology Information Systems for UVAHSC, described how his team developed a totally paper free process in which protocoling is accomplished through scanning of documents into their PACS system.

Utilizing the commonly available worklisting features found on most commercial PACS, Bassignani and colleagues detailed and employed exact steps to create an environment of paperless protocoling. One of the key features in this development was the detailed attention paid to the clinical workflow of both radiologists and technologists. In this informatics age, Bassignani states, "it's not only important to migrate workflow from the paper to the paperless environment, but it should be done with an eye to improving the workflow process."

Just when we thought the paper chase was coming to an end, the challenges of integration rear their ugly heads. "Whether we are faxing or scanning [orders], we are still required to handle paper," says Bassignani. As we work to trim costs, improve patient care and increase quality and efficiency, PACS may offer several advantages to radiology practice. However, on the other hand, "in a complete paperless world, RIS may be the one to suffer and not be able to handle the work load," he adds.

In an industry with shrinking margins, limited resources and increasing complexities, being highly efficient is critical and quality should not have to suffer.

The quality of images accepted for interpretation in our digital radiology environments are often described as inferior to say the least.

QA is a critical function, says Dr. W. James Sehnert, Carestream Health Inc. "It holds ramifications on diagnostic accuracy, department workflow, productivity and, more importantly, patient safety." Often driven to increase productivity and workflow, radiographers may not be entirely objective when assessing the quality of their own work.

Utilizing a large database of radiographs and associated metadata collected over a five-month period, Sehnert and researchers investigated the differences in the quality of radiographs that were produced in dissimilar workflow environments. Both QA-accepted and QA-rejected radiographs were included. Nine board-certified radiologists participated as readers in the study.

Of the QA-accepted radiographs included in the study, there were a total of 216 PA chest exams and 426 portable chest exams. Radiologists determined that 18 (8.3 per cent) of the PA chest radiographs and 122 (28.6 per cent) of the portable radiographs were sub-diagnostic, indicating that radiographers are more likely to accept subdiagnostic radiographs for interpretation for portable relative to in-department chest radiography.

Researchers note that because of the wide variations in tissue attenuation within the thorax thus limiting one's ability to simultaneously assess the lung fields, mediastinum, and chest wall, chest radiography can be technically challenging. As a result of such challenges portable chest radiography has been cited as the single radiographic examination with the greatest variability in image quality. However, while there is a need to improve image quality, little has been done to standardize the QA process for portable chest radiography.

In this study researchers confirmed that QA, as practiced in portable chest radiography, is inadequate. In addition, it also indicated the quality of radiographs attained within in-department PA chest radiography is significantly better than portable chest radiography.