What is an Order Exception?
If a new Ultrasound Study was received but there is no RIS scheduled record by the Patient ID/MRN and Accession Number then that study on the Imorgon Server is marked as an "Exception."
What Do You Need To Verify Orders?
There are two ways we can do this. One is to get HL7 ADT feeds from your RIS. Another is to look in the Modality Worklist you are already using clinically.
| || Advantages|| Disadvantages|
|Modality Worklist Method|
- Extremely quick to implement.
- Normally do not incur any additional cost from the RIS vendor.
- If worklist is created at least one day ahead of the schedule then prefetch can also work efficiently from this list.
- Cannot be used for Prefetch if the customer workflow is "just-in-time" creation of worklist entry*.
- May not contain study details like study description, location, attending physicians name etc.
- Cannot be used for updates and merges of demographics and studies.
- Prefetch can work very efficiently since more advanced schedules can be obtained.
- Can obtain detailed study information such as study description, performing location, attending physicians, referring physicians etc, which can be displayed in the study list or worksheet.
- Can be used for updates and merges of demographics and studies.
- Implementation is complex.
- May incur configuration or consulting fees from the RIS vendor to create an outgoing
Straight Pass Through**
- Very little configuration needed.
- Ultrasound images are available both in Imorgon and PACS at the same time.
- Customer can plan and configure the pre-staging of priors using the PACS's pre-staging feature.
- All exceptions must be handled on the PACS.
- May lack the study description for the radiologists.
- Need to rely on the PACS Pre-Staging on Priors.
* In order to reduce the chance of erroneous study selection, some customers set up the modality worklist to show only "one line" of study by scheduling studies on the RIS just when it happens. This is a valid mode that can be used for validation but it will take several minutes to pre-fetch the relevant priors back into Imorgon server, this method may cause "missing priors."
In all modes of verification, there is also "Smart Just-In-Time" prefetch that can be enabled. This means that the server will try to fetch relevant priors for an MRN indicated in the DICOM image object just received regardless of whether we find the MRN in HL7 or MWL. This will get around the situations when, for example, your HL7 feed is down, MWL server down or Ad hoc orders being placed.
** Straight Pass Through can still be implemented per Source AE Title basis regardless of the workflow mode in use. This is often a requested configuration for covering scanners that will be used in ER, Off-Hour scanning or non-radiological clinics such as covering Ultrasound genetics departments. In this mode, for example any images received from an AE Title of ER_IU22_01 can be sent immediately to iSite ignoring any validations.
I Can Fix Exceptions on My PACS. So Why Do I Need To Fix Exceptions on Imorgon?
- Images that exported through Imorgon to the PACS are already going to be validated against your order records, therefore you will experience a significantly less radiology service calls to fix exceptions since your Imorgon system provides the QA.
- In standard workflow scenario, Imorgon server is configured so that any registration exceptions will prevent the export of images (of the exceptioned study) to the PACS until the exception is fixed on Imorgon. This fix can be done within the Imorgon workstation by any authorized user such as sonographers or physicians. Often this fix can occur automatically especially if you have add-ons or emergency cases in which the order follows the acquisition.
- Imorgon has its own patient and study database. This has to be in sync with your "system of records." For example demography updates or changes must also be taken care of at both your PACS as well as on Imorgon system. This is why we need an access to order records either through HL7 or Modality Worklist.
What Happens if there is an Exception?
- The study will be marked as an exception. There is an Exception Flag column in the Study List of the Workstation. This column may or may not be hidden, but you can activate it.
- If the study cannot be exported to the PACS (in most cases) then the study will be held in the queue until the exception is corrected. This is so that the PACS archive administrator does not need to correct the exception.
How Would Imorgon Know About Orders?
Your Imorgon Server can be configured in one of two ways,
- Take new order information from the Modality Worklist (most likely the same list you use on the Ultrasound Machines). The Imorgon system periodically query the worklist to register new orders. In most institutions orders are scheduled hours and days ahead of time.
- Take new order information from the HIS or RIS HL7 feeds. This is more sophisticated and also more robust ways for the Imorgon server to register new orders. Because of the cost and time involved in implementing this technique, some customers perfer using the Modality Worklist based approach even though you may know that there are HL7 feeds in the hospital networks.
- Note also that if neither of the approaches are available, there will be no exception detection.
How Would an Order Exception Happen?
In general if a matching scheduled Patient ID (MRN) and Accession Number is not found against a study received on Imorgon Server that will trigger an exception.
If your site has an HL7 order feeds from HIS or RIS into the Imorgon Server, the HL7 information is used to register an order. If your site has a Modality Worklist then it will be used for the same purpose. Only HL7 or Modality worklist will be used and not both at the same time.
- It is an Emergency case and there has not been any schedule in the RIS.
- A study was never scheduled in the RIS.
- A study was started but but scheduled "after the fact" at the RIS.
- There was a technical problem with the HIS or RIS such as HIS or RIS down, network problem, or a problem with the Imorgon Server. and prevented the modality worklist or HL7 orders information from propagating and registering in the Imorgon Server.
- A study was started manually without the use of the Modality Worklist.
- A study was entered manually but there was a spelling or typographical errors in MRN or Accession number field(s).
How Can You Correct It?
- You can correct the exceptions immediately at the workstation. The user interface enables you to pick the correct order from the modality worklist or HL7 order list.
- A step-by-step guide is available here.
What Happens After I Correct the Exception?
- The images will be queued for PACS archive export, if it is so configured.
What If I Still Cannot Find an Order, But I Know the Correct MRN/ Accession
- You can manually edit the study on the workstation, then if necessary manually export that to the PACS.
An On-Call Physician or a Resident Needs To See The Images Right Away on the PACS, What Can I Do?
- You can override the non-export condition by Manually Exporting the study. This will likely cause an exception on the PACS side, however, the images will be viewable.