GUIDE TO IMPLEMENTING ORDERCOMMS IN RADIOLOGY
There are 4 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.
b.
c.
d.
Automatic population from PAS,
choose from a list
free text entry
Automatic population from log-in details/system
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 login 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 transmitted to RIS
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 realtime 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 H):
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 ICE results 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:
i.
Low risk (Creatinine <130)---Peri-procedural oral fluid
hydration advised. Patient Informed.
ii.
High Risk (Creatinine >130)---Need for IV contrast
administration needs to be reassessed (e.g. Would a noncontrast 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.
iii. Not relevant—as patient is on dialysis
iv.
Up-to-date Creatinine levels requested
2. Diabetes (Radiology)--- (Iodinated contrast exams only –not MRI)
Is the patient Diabetic? Yes or No
a. If Yes---Is the patient on ----Diet control, Insulin, Metformin or
medication other than Metformin?
i. 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_c
ontrast.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 metallic Intraorbital 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.
ii.
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 for all
examinations) Please ensure that the patients maximum body circumference does
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, abdomen etc )
circumference does 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 for all examinations that
require Gadolinium)
“The last Creatinine level was ----- on --/--/--“ (This will be automatically
displayed from the ICE results system)
Please read Royal College of Radiologist guidance
https://www.rcr.ac.uk/docs/radiology/pdf/BFCR(10)4_Stand_c
ontrast.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: 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 data fields in Ordercomms, RIS & 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
L. CONTEXT LINKING 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.
Thus radiology department staff will be able to:
a. communicate with the referrer of any reasons of cancellation—using
electronic Mail
b. document of Ordercomms notepad (if available) any information for any
Clinical user to see.
c. allow radiology staff to review blood results with ease—Creatinine levels for
contrast exams etc
2. Ordercomms to PACS: There should also be a context link from Ordercomms
to PACS
a. At patient level on Ordercomms to patient level PACS Imaging history
b. At Exam/Report Level (after the status is updated to exam performed or
later) on Ordercomms to specific exam on PACS
M.
PAPERLESS RADIOLOGY DEPARTMENT: It is possible to have an
Paperless radiology dept but the key issues to tackle:
1. RADIOGRAPHERS PCs---Adequate number of PCs in radiographer modality
areas is crucial.
2. MISSING ORDERS---Good Regular housekeeping by admin staff in radiology
to ensure that Orders do not go missing.
3. ELECTRONIC VETTING---RIS electronic vetting module is required. It
should be easier to vet electronically—than current paper processes.
Radiologists will be able to change and cancel requests on RIS, which will feed
back to Ordercomms—with reason for cancellation.
4. RIS & ORDERCOMMS CONTEXT LINK: There should be a CONTEXT
LINK between RIS and Ordercomms, which will allow radiology staff to open
Ordercomms to the relevant patient through a button/icon on the top tool bar of
RIS.
N. ORDER OUTCOMES on RIS & COMMUNICATION:
An order may only have one of the following outcome status on RIS
1. Cancelled
2. Did Not Attend
3. Exam not Performed
4. Authorised/Verified Report
Each of these outcomes MUST be communicated with the requesting team. The
reason for exam not performed and Cancelled must populate the report text of the
results screen. These should not require other forms of communication
(letter/telephone etc)