Canisius Wilhelmina Ziekenhuis (CWZ),
Nijmegen

The Canisius Wilhelmina Ziekenhuis (CWZ) in Nijmegen brought all their medical images together in one well-oiled Enterprise Imaging system. Due to the integration with the EPR, this system works quickly, securely and efficiently.

CWZ is one of the 27 top-clinical teaching hospitals in the Netherlands. The hospital, with its main branch in Nijmegen, offers 28 medical specialisms, 8 paramedical departments and 5 urgent-care departments and IC units. Nearly 4000 employees and many volunteers provide personal care to the patients every single day.

An important challenge with every new implementation is properly defining the workflow you want to achieve per department and to integrate the modalities into this workflow. At CWZ, the closed order loop is consistently taken as the guiding principle: You send an order from within the EPR, and the images come back to the EPR, all with as few clicks as possible by the user.

“In each department, we performed an analysis based on a survey document,” says Jeroen Blankenspoor, Application Coordinator within the project team. “We look to see which devices we have and whether any extra devices are needed. Then, we decide how we will connect these devices to Enterprise Imaging and the EPR in as standardized a manner as possible – after all, an ultrasound is an ultrasound, no matter which department is using it. After that, we work out which data must be migrated, either because migration is necessary for the care provided or because it is required by law. As the last step, we write a manual and provide training.”

His colleague Astrid Bakker continues: “Making an inventory of the devices and figuring out how to convey the orders to the device and how the images can then be returned – that takes the most time. Things have to be done technically, but also functionally, both on the EPR-side as well as on the PACS-side. Sometimes, you also need the supplier of the device, because the process for transferring images is not standardized. Older medical equipment sometimes does not transfer any data at all, and then there is nothing to digitize. That is why nowadays when you purchase a new device, it must be able to provide images in DICOM format and to receive HL7 orders.”

In addition to that, security is also an important part of the analysis: Who can see the images? Some departments want to protect the images more than others. That must also be regulated, both on the PACS-side and on the EPR-side.

And then there are the emergency examinations which are accompanied by extra workflow challenges, especially on the EPR-side. How can you ensure that the orders actually end up in the Enterprise Imaging work lists? This analysis is also very important.

“One of the departments where we have set up the closed order loop is Dermatology,” Edwin van Harn, one of the team’s Functional Application Managers, tells us. “There, they took photos with a camera and these photos were saved somewhere on a network disc. Now, an order is created in the EPR. With the Capture tool from AGFA’s universal viewer, XERO, we can add the photos that were taken to the order in a simple and secure manner. That way you can link the report and the images to the actual request, and all the patient data ends up in a secure place.”

“We were also able to achieve added value quickly in the Clinical Neurophysiology Department,” explains Lauri. “One examination that I would like to single out is the duplex ultrasound. In the past, the images from that examination were printed out, glued to a piece of paper and scanned again, if needed. The act of printing and scanning them resulted in such a significant loss of depth and grey scale values that the images lost all their diagnostic value. The images were secured by burning a DVD directly from the ultrasound device that had produced the images. And this DVD ended up in a locked cabinet which was only accessible to the people in the department.

But now, because all images are managed centrally in AGFA HealthCare, all these unnecessary operations are no longer required. The measurement values, which in the past had to be manually typed out, are now automatically entered into the EPR. This saves quite a bit of time and helps prevent errors. The images and results can be retrieved together from a logical location. And, what’s more, it’s quick – so the patient’s course of treatment is not delayed.”

Especially those departments that had to wait somewhat longer and that have all kinds of work processes that are labor-intensive – they have welcomed the project team with open arms. “I am positively surprised about the enthusiasm with which this is being taken on board in the departments and about how everyone is putting their backs into achieving this. Knowledge, competency, commitment and passion from the people. I see that over and over again in all the departments,” says Dirk.

In the past, everything was segregated. The images could often only be viewed by the specialist who had performed the examination and not by those who had not submitted a formal request. Or the images were located somewhere that the user thought was very logical at the time, but they could not be easily found later on.

“For the specialist, it is handy to have all the images from one patient, together with the results, stored away neatly in one system,” explains Barbara. Now they can inspect the images using the XERO Viewer that is integrated into the EPR. Not only are the images easier to locate, the whole process is just much faster.”

“According to me, it is also important from a multidisciplinary point of view. A doctor from a different department can see the examinations a patient has already undergone,” observes Lauri. “Imagine you have a lung disorder. In addition to the CT scan of your lungs, you have also had a neurological exam which may also be correlated to your symptoms.”

The opportunity to avoid double examinations is also of enormous benefit to the patient. In the past, if a cardiologist ordered the same exam as the neurologist, that would go unnoticed, but not anymore.

“By centralizing all the medical images in one well-oiled system, everything becomes easier to manage and control. And when a system has fewer links, you can raise the overall security to a higher level while reducing the chance of errors,” continues Arnaud.

And, within the new platform, a log is automatically created of who views which images when. All measures for safeguarding the security of the platform. And because the images are now all in one place, they have a better overview of, and choice of, the retention periods for the images than they did when they were stored in many decentralized locations.

“With this system we have also created the opportunity to examine possible next steps, such as improving the exchange of images with other hospitals and care professionals in the region (via XDS), making the images accessible to patients and applying AI for decision support. Consider, for example, algorithms for COVID-19 screening, which are of great interest currently and which, of course, the hospital is already using,” adds Dirk.

“And the benefits are not only qualitative. If you look at the cost of the system, this was definitely an attractive business case. The fact that we can phase out the old systems, limit the administrative burden and agree to better conditions with the supplier means seriously positive returns for our hospital,” concludes Arnaud.