Let's face it, IT speak isn't something we learned in medical school. There are a lot of terms that are unfamiliar to physicians when talking about imaging workflows. Moreover, many terms are acronyms that are thrown around like candy at Halloween. The first step to understand an imaging workflow is to understand these terms. Below are two resources that are excellent starting points to understand these basic terms and their definitions. 

"Understanding IT Speak 101" by Rob Ferre and Dave Hennon

"IT Basics and Definition of Terms" by Rob Ferre and Christian Dameff

There are two types of imaging workflows. The traditional imaging workflow is called an "Order Based Workflow." This workflow begins when an order is placed to begin the workflow process, hence the name. This workflow has been around for decades and is how radiologic studies go from an order to an imaging study that has an interpretation and a link that allows the image to be viewed within the electronic medical record (EMR). 

The second type of imaging workflow is called an "Encounter Based Workflow." This workflow begins when an image is obtained as part of a visit within a healthcare facility. Images are obtained by physicians as part of a procedure (e.g. colonoscopy) and archiving those images with an attached report is needed. In order to get these images into a long term storage solution (e.g. PACS) with an attached report within the EMR, certain requirements are needed. These are accomlished using an encounter based workflow.

To learn more about the differences between an order and an encounter based workflow, including a flow diagram, click here. 

In September 2021, a survey was conducted about workflow preferences for emergency ultrasound workflows. There was strong consensus surrounding four items by emergency ultrasond experts who completed the survey. These included the following:

1. An encounter-based workflow was desired over an order-based workflow

2. A simplified solution to quickly entering patient data was needed (e.g. barcode scanner) 

3. Remote login function to the workflow system was essential

4. Emergency ultrasound experts wanted the ability to customize their own worksheets based on their local needs

To access a presentation on the data, click here or you can access this from "The Data" tab on the top of this page. 

In 2020, a workflow process map was created through the ACEP Emergency Ultrasound Section's Industry Roundtable that mapped out the process of an encounter based workflow from the perspective of an Emergency Ultrasound Director. The map provides detailed insights into the POCUS workflow process and potential areas for design improvement. This map is available here.

A POCUS workflow must to be efficient, reliable and clinician-centered in order to have sufficient buy-in to actually be used in clinical practice. While there are important elements in a workflow that need to account for new learners that do not yet have POCUS privileges, a successful POCUS workflow should be designed from the perspective of the clinician actually performing the exam. From the clinician using POCUS in the clinical space, there are 5 key touchpoints where physicians potentially interact with a component of the workflow. These inculde the following:

• • The decision to perform a POCUS exam

  • Performing the POCUS exam

  • Documenting/Signing the POCUS

  • Importing the results of the POCUS exam into the physician note

  • Ability of other clinicians to see the interpretaion of the POCUS exam / POCUS images associated with the exam

Based on prior work, including a 2021 Survey to ACEP Emergency Ultrasound Section members, a strong majority of the Emergency Ultrasound Community prefer an encounter-based workflow. In considering how to make this workflow more efficient, reliable and clinician-centered, the IRT leadership is asking vendors to commit to the following:

All Vendors:

Will you participate in a POCUS Workflow Standards Workgroup by sending a senior engineer to help establish best practice standards and work to create appropriate DICOM tags and an IHE recoginzed encounter based POCUS workflow profile? Send name and title of representative to Rob Ferre, rferre@iu.edu or Rachel Liu rachel.liu@yale.edu by Nov 1, 2022.

Cart Vendors:

1. Will you make a barcode scanner an “opt out” for all machines sales to Emergency Departments?

2. Will you work with your preferred barcode scanner such that barcode scanners include a 2-click process where one click inputs patient identifiers (e.g. an auto-query of a MWL or similar) and another click inputs the clinicians unique identifier into the appropriate ID field on the patient information page (e.g. EMR or middleware login)? Other means, such as RFID recognition through Impravata, may also be another means to accomplish this same goal of accurately identifying the user.

3. Will you train your Sales Representatives and Clinical Application Specialists to set up the barcode scanner and assist with integration of this 2-click process during the installation of new machines in Emergency Departments?

Hand Held Vendors:

1. Will you create a workflow process to easily capture the patient ID with the phone/tablets camera?

2. Will you create a workflow process to easily capture the user ID with the phone/tablets camera?

3. Will you create an online tutorial for users on how to use the camera to input this workflow data?

How will we follow up on these requests? 

Physicians leaders from the IRT meet every other month. We will track these and publish which vendors have met these requests on this webpage. Please send questions or notification of completion of these requests to Rob Ferre, rferre@iu.edu.  

In 2022, a collaborative group of emergency physicians, informaticists, and representatives from both the ultrasound and electronic health record industry formed a work group to examine and create best practice standards around POCUS workflows. The purpose of this work group was to examine current workflow processes and published IHE profiles with respect to POCUS workflows and to optimize or propose new industry standards. 

Background Documents: The following have been published regarding POCUS workflows:

• IHE Encounter Based Imaging Workflow Profile. This describes an encounter based workflow profile where images need to be stored in a vendor neutral archive and displayed within an electronic health record. One of the use cases in this profile includes POCUS (page 47). 

• IHE PowerPoint on Encounter Based Imaging Workflow. This provides a summary overview of the encounter based workflow as developed. 

• ACEP IRT "Emergency Ultrasound: Workflow White Paper". This paper describes workflow requirements for documenting POCUS exams within the electronic health record.

Work Group Documents: The following documents have been presented as part of the workflow work group meetings

• PowerPoint presentation on the "Overview of IHE EBIW Profile and Processes" by Steve Nichols

• IHE EBIW FHIR Draft Document

Workflow Presentations:

• Workflow overview and update: SCUF 2023 Presentation.

SCUF Workflow Presentation: This presentation covers the basics of workflow and the development of standards, including the ACEP EBIW IHE Workflow update.

Clinical Use Case: Clinical Use Case

Educational Use Case: Educational Use Case

Split and Merge Exception Case: Split and Merge Use Case 

Procedural Use Case: Procedural Use Case