Boston Medical Center shortens MR exams and increases radiology workflow efficiency

When Kevin J. Chang, MD, was appointed Director of MRI, his focus was on getting better control over runaway exam lengths and bringing more consistency to imaging. “Neuro exams were complex and long because a different attending physician often requested multiple optional, time-intensive pulse sequences,” Dr. Chang says.

Philips PerformanceBridge Protocol Manager is designed to improve standardization across a fleet of MR systems and save time by managing protocols from a central repository. Authorized users access a browser-based protocol portal on their computers to remotely view protocols, edit more than 400 scan parameters and distribute protocols over connected MR systems. The analytics dashboards help identify protocol optimization and standardization opportunities and help users monitor protocol use and performance.

BMC had begun optimizing and limiting protocols before using PerformanceBridge Protocol Manager but found the process very cumbersome. “If we wanted to edit a protocol, we had to schedule it in advance by either finding an unused time slot or blocking off time, so we had access to the scanner interface,” Dr. Chang explains. “It disrupted our clinical schedule. Trying to schedule time on the scanner to make these protocol changes was a nightmare, much less test out the protocol changes after the fact. With Protocol Manager, we can edit protocols at any time, without disrupting scanner use.”

Since installing Protocol Manager, volume has increased by 3 studies per day, which translates to an additional $324,000 per year.¹

Only a small group, consisting of Dr. Chang, Jude Ierardi, Manager of MRI, and Sara Martin, the department’s quality assurance specialist, are authorized to edit protocols. However, all the radiologists and technologists were involved in the selection process. Ierardi credits having the radiologists review and agree to the protocols as key to the successful implementation of Protocol Manager. She adds that she and Dr. Chang facilitated communication between the radiologists and the technologists, which helped solidify common goals.

The team’s first step confirmed which exams were ordered most often. Next, they prioritized standardization for those exams. “Neuro exams make up 70% of the exams conducted on the Philips scanners, so that became our top priority,” Dr. Chang explains. “I’d like to thank Dr. Osamu Sakai, Chief of Neuroradiology, whose dedication to finding ways to decrease neuro exam times without impacting quality was instrumental to the success of this project.

“In every category, we checked how often exams were over the time limit to determine which protocols needed to be shortened. Then we reviewed those protocols with section radiologists to learn which pulse sequences they thought were least important or the most redundant. Finally, we marked those specific pulse sequences either for elimination or acceleration.” Once the new protocols were chosen, they were tested, edited if needed, and made available on the scanners. The standardized protocols are locked in to prevent unauthorized changes.

Ierardi states that the number of sequences and the choice of sequences had the most impact on exam length. Technologists often chose sequences they were most familiar with rather than using more recently developed options. For example, incorporating Philips Compressed SENSE and mDIXON in protocols helped shorten exam time while also reducing artifacts.

Ierardi instituted refresher training to help the technologists feel more comfortable with newer sequences and acceleration techniques to remedy this problem

After three months with PerformanceBridge Protocol Manager, the results are already clear. Sequence time has dropped by nearly 10 minutes for brain studies and 3.4 minutes for all exams. L-spine and T-spine studies have decreased by 3 minutes, and C-spine studies have reduced by 8 minutes.

In addition, volume has increased by three studies per day, which translates to an additional $324,000 per year. The volume increase was measured between February and April 2021, after elective exams volume had begun to return.¹

Dr. Chang points out that the new protocols also shortened reading time and increased workflow efficiency because at least one sequence was eliminated from all routine spine and brain exams.

Dr. Chang and Ierardi note that while the goal was to shorten exams, the new protocols do not sacrifice image quality and often improve it.

“Our goal is for the referrers to not notice any protocol changes, except to be pleasantly surprised by improvements in image quality. For abdominal imaging, the referrers noticed that the image quality has gotten better and that more patients can get through the scans as well, with fewer breathing artifacts,” says Dr. Chang, who specializes in body imaging. “One of the biggest advantages of pulse sequence acceleration in abdominal imaging is that it reduces respiratory motion artifacts.”

Locking in exams also improved consistency. “Before we standardized protocols, I had some technologists who always obtained stellar images, but it wasn’t consistent among technologists. It certainly wasn’t consistent between the scanners,” Ierardi explains.

Dr. Chang, who is also an associate professor of radiology at Boston University School of Medicine and an adjunct associate professor at Brown University Alpert Medical School, adds that consistency is essential because BMC is a teaching hospital.

“MRI is one of the most daunting modalities to learn during residency and fellowship education, mostly because of the sheer number of pulse sequences involved,” he says. “The more consistent the protocols are, the easier it is for residents and fellows to interpret a scan. And often the more complex a protocol is, the less apparent it is to a resident or a fellow when the protocol hasn’t been done correctly, or when there’s a missing pulse sequence.”

Implementing PerformanceBridge Protocol Manager also serves a larger patient goal. “Many of our patients have limited access to healthcare, and an MRI appointment can be difficult to get because we have only three scanners for this large population,” Dr. Chang points out.

“Shortening scan times and improving workflow efficiency increases access to MRI for patients who otherwise may not have been able to get an exam in a timely fashion. I think all patients should have equal access to the imaging services they need for their clinical care, regardless of their insurance status and ability to pay. So, anything I can do to shorten the time from scheduling to examination to increase the number of patients who can get timely medical care is better. And I think that’s what serves our hospital’s mission to the city of Boston.”