The installation and implementation of a hospitalwide image management system and a speech recognition dictation system has had a dramatic and positive impact on radiology report turnaround times at Elmhurst Hospital Center, a 543-bed municipal teaching hospital located in New York City's Borough of Queens. The "lost film" problem has been eliminated. As a result, the percentage of unreported examinations has dropped from 25% to less than 1%. These performance improvements have significantly benefited the entire medical staff. With the successful implementation of a HL-7 standards-based radiology information system (RIS), a speech recognition dictation system, around-the-clock staffing of Board Certified radiologists, and a picture archiving and communication system (PACS), report turnaround time improved dramatically. Eighty-six percent of all examinations now are reported formally within a 12-hour period compared with a 3% average before implementation of the changes. However, with the use of the PACS and speech recognition technologies, new problems have arisen within the radiology department. These technologies, designed to enhance communications capabilities, also have significantly reduced the amount of clinician/radiologist dialogue. Easy and rapid access to patient images and reports has had a detrimental effect on that face-to-face consultations with clinicians, which were commonplace before PACS, and now have almost completely disappeared. The radiologist/clinician interchanges, which occurred frequently before a final report was dictated, often resulted in better understanding of the clinical problem and, hence, a more meaningful final report. Although a conferencing feature to facilitate communication exists within the PACS, it is not utilized by the clinicians. The dilemma is that as information about patients is made more available to the hospital staff, less information is provided about patients to the radiologists. Although the speech recognition system benefits the hospital, its staff, and the patients served by reducing clinician time awaiting a diagnostic report and reducing clinic and emergency room waiting time by the patients themselves, it does not necessarily benefit the radiologists who use it. Speech recognition dictation systems slow down the individual productivity of the radiologists' dictation process by at least 25%. Radiologists are assuming the role of transcriptionists as well as diagnosticians. Mistakes occur that would not with the use of a traditional dictation system and professional transcriptionists.

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Many large urban hospitals converting to filmless radiography use a phased approach for digital imaging implementation. In fact, this strategy often is recommended by picture archival communication systems (PACS) experts and vendors alike for large, busy hospitals installing PACS in existing physical facilities. The concern is that comprehensive conversion from film-based to digital imaging may be too overwhelming an adjustment in operations for a medical staff to effectively handle without serious disruption of workflow for patient treatment and care. Elmhurst Hospital Center is a 543-bed hospital located in the Borough of Queens in New York City. Owned by the New York City Health and Hospitals Corporation, this municipal teaching hospital provides services to a patient mix that is 38% indigent with no insurance, 50% covered by Medicaid or Medicare, and 12% affiliated with HMOs. Most inpatients are admitted through the emergency department. Forty-five percent of all radiology procedures conducted are for emergency patients. Historically, up to 25% of all diagnostic imaging examinations were never reported formally by radiologists. Report turnaround time for the remaining 75% was unacceptable, with only 3% of all imaging examinations reported within a 12-hour period in 1996. Both situations existed in great part because physicians and residents who felt they needed access to films simply took them. Many were never located or returned days after they were taken. In 1998, Elmhurst Hospital Center replaced its RIS and added voice recognition dictation capabilities in January 1999. A hospitalwide PACS was deployed 10 months later. With the exception of mammography, the hospital converted to filmless radiography within 60 days. The critical objectives to maintain control of films and radically improve the reporting process were achieved immediately. Over 99% of all examinations now are formally reviewed and reported. Only 7% of all reports take 1 or more days to generate. This report describes Elmhurst Hospital's efforts to make improvements in the delivery of radiology services and the reasons attributed to its rapid conversion to becoming a filmless (mammography excluded) medical center. The impact of the PACS on radiology department operations and service is discussed.

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