1300 modalities, 1500 radiologists, 1500+ technicians, 10,000 referring physicians, 500,000 patients… Moscow’s Unified Radiological Information System (URIS) and its unified digital infrastructure have become a ‘one stop shop’ to access patient imaging data across the megalopolis and beyond.

And a core component of URIS is the unified Enterprise Imaging platform, offering the scalability and functionality for the present and the future of this ambitious project.

The overall goal was to integrate all local radiology services into the URIS service; the first challenge was connecting multiple modalities from different sites by February 2015- only one month after the signing of the contract. By mid-2015, all the CT and MRI modalities from the primary care and out-hospital facilities were not only connected but integrated in the advanced diagnostic workflow automated by Enterprise Imaging.

Professor Morozov: “Different workflow approaches were implemented, such as cross-reporting, where radiologists at one primary care and out-hospital facility would report studies carried out at another primary care and out-hospital facility. True teleradiology and remote reporting, dashboards for productivity analysis and peer review, were also tested, with more modules added to make this possible. We continue to tune these approaches, with the support of the Agfa HealthCare application specialists”

In 2018, the project took a huge leap forward, when the city’s new vice-mayor in charge of healthcare decided to leverage all of the informatics, by having all CT, MRI, mammography, digital X-ray and X-ray angiography devices in hospitals and primary care and out-hospital facilities connected to URIS by the end of 2019.

The task-based workflow management is a key functionality in Enterprise Imaging for each radiologist on the platform. It adds value not only for the radiologists, but also for technologists, referring physicians, patients and the healthcare system overall. “Worklist management based on automated task assignment enables us to distribute studies among our radiologists, based on subspeciality rather than location. Every study is thus reported by an expert in that subspeciality, not, for example, the radiologist who happens to be in the hospital or primary care and out-hospital facility on that day.”

This distributed way of working has had several very important benefits for radiologists across all locations, he continues. “Firstly, we can reduce second readings, because every report is already an ‘expert’ report. Secondly, radiologist satisfaction has increased, because these professionals are working with their familiar studies and pathologies.

Furthermore, as the radiologists have the specific knowledge needed for the studies they are working on, report turnaround time has drastically improved. Five years ago, it was five days. Now it is on average less than one hour! This is a very important metric for patient care quality, as it means the referring physician and the patient have access to the diagnostic information much more quickly.”

Other functionalities enabling a more comfortable and efficient workflow for radiologists include the ease of switching from one working place to another, and helpful tools such as hanging protocols.

Beyond the centralized reading and reporting services at the MRC, the digital infrastructure and unified platform have enabled a standardization and harmonization of radiologist workplaces in every hospital in the city. “This allows us to smoothly transfer images from the primary care and out-hospital facilities to the hospitals, which reduces repeated studies,” describes Professor Morozov.

The XERO universal viewer plays a key role, providing “anywhere, anytime” access to the patient’s imaging record – not only for the radiologist, but for all stakeholders. “Radiologists might use XERO to quickly and remotely check a patient study that requires specific attention, for instance. And in the future, I am convinced the XERO functionality will be an important step in truly freeing radiologists from their physical locations,” he explains.

As new service lines have been connected to the digital infrastructure, other specialists have been increasingly making use of the functionalities, as well. “When we connected the angiography devices, vascular surgeons began using the platform to inform about their decisions regarding operations on stroke and myocardial infarction patients, for example. Traumatologists and ENT surgeons also use it, to check CT, MRI and X-ray results.”

Private PET-CT centers such as those specializing in oncology imaging are also connected, giving referring oncologists at the hospitals access to the PET-CT scans taken at those private centers. And with XERO embedded in their electronic health records, referring physicians can directly check patients’ images: in the last year, nearly 10,000 did so.

Patients also have easier access to their own information: 500,000 patients have downloaded their imaging studies and reports from their electronic health records. “This access empowers the patient, making it easier for them to get a second opinion, for example. Looking back 20 years ago, patients were ‘bound’ to their healthcare provider literally because of the notoriously bad handwriting of the doctor: it wasn’t legible, so only the doctor had full access to these notes. Now, patients can take their data anywhere.

It also raises the possibility that several years in the future, a patient may come back and say ‘you missed a tumor in this lung image, and now it has grown from 1 mm to 10 cm’. But it is always better for the healthcare system to have information, rather than not have it. This kind of pressure on hospitals and physicians, which drives quality improvement, is good for everyone in the end.”

“The Enterprise Imaging platform includes an online collaboration functionality, that enables a radiologist to contact a more experienced radiologist for support with a diagnosis. Peer review for us is definitely not only about quality review, but about creating a learning environment. The radiologist requesting the second opinion is learning from their more experienced peer. Normally, these consultation requests decrease over time. When they don’t, we can monitor the situation and determine if the radiologist could benefit from some additional training. This provides more objective feedback and encourages more learning,” Professor Morozov describes.

Peer review can also help to highlight possible discrepancies in reporting, for example a missed diagnosis or missed incidental finding. “It’s important that the reading specialist pay attention to everything in the image, not just the ‘target’ area. For example, if the expert is looking at an aortic CT, and misses an ovarian tumor that is visible in the image, this is not acceptable. Peer review has enabled us to have very constructive discussions to make it clear what we expect, and that someone is watching and checking, to promote continuous quality improvement.”

While digital technologies in healthcare are fundamental to achieving the productivity, cost and care benefits Professor Morozov has outlined, it is important, he says, to remember that technology is an instrument, and the heart of both healthcare and technology is people. 

The flexibility and dedication of the Agfa HealthCare team have played a critical role in the stages of the project over the years. Most recently, for example, Agfa HealthCare team resources have been instrumental in integrating a local, third-party voice recognition system, as well as for testing the integration with a number of AI algorithms.

“Furthermore, from the beginning, you have to keep in mind the people who will use the technology, how they accept it, whether they are ready for it, etc. And this digital infrastructure we have built with Agfa HealthCare is ultimately about people: including the local, technical and project expertise Agfa HealthCare has brought. I am very pleased that Agfa HealthCare is part of this project.”