Current Problems in Diagnostic Radiology 45 (2016) 101–106

Current Problems in Diagnostic Radiology

journal homepage: www.cpdrjournal.com

Disruption of Radiologist Workflow

Akash P. Kansagra, MD, MSa,n, Kevin Liu, MDa, John-Paul J. Yu, MD, PhDb
a
Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, MO
b
Department of Radiology, University of California, San Francisco, San Francisco, CA

The effect of disruptions has been studied extensively in surgery and emergency medicine, and a number of solutions—such as preoperative checklists—
have been implemented to enforce the integrity of critical safety-related workflows. Disruptions of the highly complex and cognitively demanding
workflow of modern clinical radiology have only recently attracted attention as a potential safety hazard. In this article, we describe the variety of
disruptions that arise in the reading room environment, review approaches that other specialties have taken to mitigate workflow disruption, and
suggest possible solutions for workflow improvement in radiology.
& 2015 Mosby, Inc. All rights reserved.

Introduction
Society has recognized the role of disruptions in creating
accidents and mishaps. Wherever the ensuing mishaps have the
potential to cause harm or loss of life, society has enacted
restrictions to minimize disruptions of normal workflow. For this
reason, drivers in many states are prohibited from sending text
messages or using handheld devices while driving, and airline
pilots are mandated to maintain a “sterile cockpit” during critical
phases of flight where only mission-related tasks are discussed.
Medicine—where disruptions can easily cause harm and loss of
life—has also started to respond to these challenges. The most
publicized and mature examples to date involve the use of
preprocedural checklists before surgery or central line insertion
to enforce the integrity of critical safety-related workflows, result-
ing in dramatic improvements in patient safety and clinical out-
comes.1-3 However, the potential for significant workflow
disruption extends far beyond periprocedural care. In a busy
radiology reading room, for example, radiologists must contend
with a complex and fast-paced workflow characterized by fre-
quent disruptions, disruptions that may be particularly problem-
atic given the high cognitive demand of image interpretation.4-6
Unfortunately, the nonstandard nature of most radiology work-
flows reduces the potential effectiveness of basic interventions
such as checklists and may require more sophisticated solutions.7
In this review, we describe the workflow disruptions with
which radiologists must contend in daily practice, highlight steps
that other specialties have taken to respond to workflow disrup-
tions, and suggest measures that can be taken to mitigate similar
disruptions in radiology. It is our hope that this review will draw
n
Reprint requests: Akash P. Kansagra, MD, MS, Mallinckrodt Institute of Radi-
ology, Washington University School of Medicine, 510 S. Kingshighway Blvd,
Campus Box 8131, Saint Louis, MO 63110.
E-mail address: apkansagra@gmail.com (A.P. Kansagra).
attention to the urgent need for improved clinical workflow in the
reading room and provide a blueprint for safer and more effective
radiological care.
Workflow Disruptions in Radiology
The working environment in diagnostic radiology has under-
gone a tremendous change over the past 2 decades because of the
widespread adoption of filmless imaging, introduction of speech
recognition systems for report dictation, and the incorporation of
electronic medical records (EMR) into an increasingly information-
rich interpretive workflow.8 Unfortunately, the promised efficiency
gains of these systems have been partially offset by a paradoxical
increase in the complexity of radiologists’ workflow. This complex-
ity reflects a number of converging trends, including the central
and growing role of medical imaging in patient evaluation and
management, as well as increasing fragmentation and disruption
of interpretive workflows. In addition to their primary task of
image interpretation and reporting, radiologists in modern prac-
tice must shoulder added responsibilities that can include frequent
telephone communication, in-person physician consultations,
technologist supervision, patient consent, ultrasound scanning,
and management of contrast agent injections and adverse reac-
tions.4,5,8 Although these additional tasks are important, they
distract and detract from the primary workflow of image inter-
pretation, create barriers to productivity, and likely contribute to
errors in the knowledge-intensive service environment of clinical
radiology.9
Of these many potential sources of disruption, telephone
communication is particularly problematic, in part because many
different sources of disruption are funneled through this common
communication channel. As an example, incoming telephone calls
may come from clinical providers inquiring about imaging findings
or selection of appropriate imaging tests, or from technologists
requesting “scan checks” to assess study adequacy or seeking

http://dx.doi.org/10.1067/j.cpradiol.2015.05.006
0363-0188/& 2015 Mosby, Inc. All rights reserved.
102 A.P. Kansagra et al. / Current Problems in Diagnostic Radiology 45 (2016) 101–106
guidance for image acquisition (eg, protocol selection or solutions
for specific technical challenges). Similarly, outgoing phone calls
are often directed to providers to communicate time-sensitive
imaging findings or solicit additional patient information. Recent
work by Yu et al5 describes their experience with telephone-based
disruption of on-call radiologists’ workflow. Their work reveals
telephone interruptions of radiologists on a surprisingly large
scale, with more than 10,000 after-hours calls directed to a single
resident over a 3-month period. Incoming telephone calls occurred
as frequently as once every 4 minutes during peak hours, which
translated to roughly 2-3 expected interruptions during interpre-
tation of a single CT of the abdomen and pelvis. Related work by
Balint et al4 has suggested that the frequency of telephone
disruptions in the hour preceding resident interpretation of a
study was positively correlated with the likelihood of an incorrect
interpretation.
Importantly, disruptions to radiologists are not confined to the
reading room; dysfunctional or inefficient workflows in other
areas of the radiology department can secondarily increase bur-
dens on radiologists. For example, inadequate systems to identify
and triage patients for imaging may create a need for frequent
radiologist involvement in study prioritization.8 Similarly, poorly
designed systems for information transmission between different
members of a radiology department (eg, radiologists, technolo-
gists, and patient transporters) can hinder effective care of
patients, thereby requiring increased radiologist involvement to
maintain appropriate and timely care.10
If left unchecked, the scale of workflow disruption is likely to
increase. As the information economy of medicine continues to
grow in scale and complexity, there is likely to be increased
reliance on specialties such as radiology that can create and share
objective patient information. Against this backdrop, inefficient or
ill-defined clinical workflows are likely to produce ever-increasing
disruptions to radiologists. Thus, implementing solutions to dys-
functional workflows is a key component in building and main-
taining an efficient information economy.
Managing Workflow Disruption in Nonradiological Settings
Disruptions in workflow are not unique to radiology but are
also experienced by other hospital-based specialties such as
emergency medicine,11-19 critical care,20-25 and surgery.26-32 The
solutions to these disruptions vary based on the specific workflow
patterns in each patient care setting, but they can generally be
grouped into several themes.
Filtering Interruptions by Activity
A basic strategy to improve workflow is to create physical or
temporal barriers to interruption during activities that are of
critical importance or particularly susceptible to disruption. In
some cases, this strategy may amount simply to having individuals
address potential sources of interruption at a convenient time,
such as refilling intravenous fluids before nursing handoffs to
prevent unnecessary alarming during transfer of care.23 In other
cases, physical barriers—including possibilities such as signs or
colored vests for individuals seeking to avoid interruption, or
colored floor tiles or shields for specially designated areas—may
be of value.23,33,34 These basic interventions can have a profound
effect. One study found that implementing a visible “No Interrup-
tion Zone” around a medication dispensing station resulted in a
41% decrease in interruptions,33 while another found that erecting
a wall around the medication dispensing station decreased inter-
ruptions by 81%.34 Alternatively, there may be value in gentler
approach that allows for interruptions even during critical
activities, provided the interruption conveys important patient-
related information. In this context, interruptions may be miti-
gated by increasing the transparency of task importance so that
potential interrupters can determine if interruption is
appropriate.22
Filtering Interruptions by Acuity
A large percentage of interruptions—even during critical tasks
such as transfer of care discussions (“sign out”) and clinical rounds
—are nonessential, with only 11% of interruptions during morning
sign out and 27% during morning rounds being essential to patient
care.21 As such, filtering nonessential interruptions may streamline
workflow. Young et al35 describe a system in which nurse requests
to send after-hours pages to resident physicians are reviewed by a
charge nurse and categorized by acuity, with emergent pages
transmitted immediately, urgent pages batched, and nonurgent
pages deferred until the morning. Following implementation of
this system, the total number of pages and number of nonurgent
pages sent after-hours to house staff decreased.
Asynchronous Communication
Synchronous channels of communication require simultaneous
participation of both parties, preventing the recipient of an
interruption from managing the timing of that interruption.11 In
contrast, asynchronous channels of communication provide the
recipient of a message with control over the timing of disruptions,
and this may therefore represent a practical method for acuity-
based filtering, task prioritization, and reduced communication
burden.36
Voicemail capability may be an effective means to reduce
disruption. In a study of emergency department (ED) providers
equipped with mobile phones, the lack of voicemail capability
contributed significantly to workflow interruption, as the pro-
viders were forced to immediately answer any incoming call.13
Alternatively, landlines with a clerical receptionist may serve a
similar role and help to reduce unnecessary interruptions.11
Alphanumeric pagers may also permit filtering of nonurgent
interruptions,11,37 provided that the recipient of a message is
provided with sufficient information to judge the urgency of the
page. Unfortunately, a large percentage of alphanumeric pages
contain only basic callback information, thereby preventing the
receiver from performing effective task prioritization and mandat-
ing an immediate callback to determine the acuity of the page.37 A
proposed explanation for this behavior is that synchronous com-
munication provides receipt confirmation for the interrupter;
asynchronous communication may benefit from a confirmation
mechanism to encourage broader adherence.36
Technology-Assisted Workflow
Electronic and nonelectronic whiteboards have been used
extensively in a variety of care settings to organize and facilitate
communication and workflow.36,38-42 For example, when used in
the operating room as a basic information display system, elec-
tronic whiteboards can facilitate integration of safety checklists
into preoperative workflow and aid intraoperative communication
between multiple team members.43,44
Chaotic and disruptive workflows can be further streamlined
with electronic systems that go beyond basic information display
to serve as an integrated information technology (IT) solution.45
Aronsky et al46 have described the implementation of such a
system in an ED, which allowed for easy information access,
information sharing, and decision support using data from multi-
ple hospital information systems, with resulting dramatic
 A.P. Kansagra et al. / Current Problems in Diagnostic Radiology 45 (2016) 101–106
increases in revenue, enhanced hospital-wide triage, and
improved staffing. Such systems can facilitate high-fidelity com-
munication, improve multitasking ability, and promote physician
efficiency through automated results notification and performance
feedback.47-49 Indeed, IT tools of this sort may help to reduce both
the number and the adverse effects of interruptions.50,51
Eliminating Unnecessary Tasks
Some time-consuming tasks can be entirely obviated through
process redesign or IT solutions. For instance, automated systems
to identify and physically locate patients, providers, and equip-
ment can eliminate the need for multiple phone calls and
pages.36,52 Similarly, normal triage pathways and full patient
registration can be bypassed in some ED settings,40,42,48 while
the considerable complexity of patient transfer between wards can
be avoided with acuity-adjustable beds.49
Workload Redistribution
Workload is not evenly distributed between individuals on a
health care team. For instance, junior physicians in the intensive
care unit (ICU) setting must contend with competing demands on
their attention far more often than senior physicians do.53 Accord-
ingly, sharing some aspects of workload may help to improve
overall workflow. Simulations have shown that the time efficiency
of rounding in the ICU can be dramatically improved by having all
team members share responsibility for handling interruptions,
thereby unburdening the trainee primarily responsible for a
patient under active discussion.50 Similarly, workflow in the ED
can be improved by sharing triage responsibilities among a larger
number of providers or having a pool of on-demand nurses and
physicians who can be recruited to help manage excessive
workloads.40,54
There may also be workflow benefit from transferring some
responsibilities to other appropriate individuals. For instance,
designating a receptionist or nurse to answer phone calls and
pages can help to reduce interruption to physicians.11,26 Similarly,
assigning nonphysician staff to handle basic but time-consuming
aspects of workflow such as medication reconciliation or intra-
hospital patient transfers can also promote workflow effi-
ciency.55,56 Indeed, even direct patient care tasks can be assigned
to nonphysician providers if there are clearly established protocols
of care.40,42
Physical Layout
Physical layout has been implicated as a source of greater-than-
necessary interruption. In the operating room, 33% of workflow
disruptions were attributable to suboptimal layout.57 Similarly,
intensive care units can be designed in a way that discourages
disruption of important tasks such as medication administration.52
Some authors have hypothesized that the high rate of interrup-
tions in the ICU relates to a large number of collaborating
providers being concentrated into a relatively compact space,
and that a linear arrangement of rooms along a busy thoroughfare
may lead to more interruptions than a more open arrangement
that separates patient care zones from high traffic areas.20
Strategies to Reduce Workflow Disruption in Radiology
Efficient Asynchronous Communication
When presented with emergent or unexpected findings or
interpretative discrepancies, the American College of Radiology
103
has recommended that radiologists use communication channels
other than the radiology report to convey this information to the
treating physician in a timely fashion.58 To minimize the effect of
these nonroutine communications on workflow, many practices
have developed efficient channels of asynchronous communication
that eliminate time-consuming tasks, redistribute workload away
from radiologists, or incorporate technology-assisted workflows.
A common approach is to automate communication of impor-
tant but nonemergent findings, such as lung nodules and solid
organ lesions. Johnson et al59 described the implementation of a
clickable button within their dictation software that conveyed
such findings to referring physicians via facsimile. Other groups
have reported systems to generate e-mail alerts to referring
physicians when specific, predefined statements were included
in the final report text.60,61 In an alternative approach, Eisenberg
et al62 redistributed rather than eliminated this workload by
having the interpreting radiologist submit a case to a web-based
portal and assigning a “communications facilitator” to the task of
contacting the referring physician by e-mail, telephone, or pager.
Most of these tools offered some form of receipt confirmation, and
each was effective for communicating nonemergent findings with
minimal workflow disruption and a high level of satisfaction from
both radiologists and referring clinicians.
Lacson et al63 developed an automated notification system that
could be used even for emergent findings. In their system,
radiologists were able to indicate the level of urgency of a finding
within notification software that was integrated with their picture
archiving and communication system (PACS) environment; the
system then automatically contacted the appropriate provider
using e-mail for nonurgent findings or pager for urgent findings
and documented this notification within the EMR.
Triage Assistants
As part of larger efforts to more meaningfully integrate medical
students into the clinical practice of radiology,64 several medical
schools have experimented with using medical students to assist
with triage in radiology reading rooms. Authors from at least 3
academic radiology departments have separately reported on the
benefits of paying medical students to answer telephone calls and
pages, and protocol radiology studies with the help of the on-call
radiology resident.65-67 This arrangement provides educational and
financial benefits to medical students while reducing disruptions to
radiology residents. In particular, medical students can enforce
acuity- and task-based filtering of interruptive communications (eg,
holding nonurgent communications until the resident is between
studies). Furthermore, some of the workload of soliciting history,
performing medical record review, or contacting referring physicians
could be redistributed from the resident to the medical student.
Mamlouk et al68 have taken the idea of workload redistribution
further and designated a radiology fellow as a “quality control”
radiologist on a rotating basis during daytime hours. This radiol-
ogist is largely excused from interpretive tasks but handles most
incoming phone calls from referring providers, protocols and
prioritizes imaging studies, performs real-time scan checks, and
customizes imaging for complex cases for the entire medical
center, thereby preserving an efficient and undisrupted workflow
for the remaining staff and trainees of the section. Notably, this
solution simultaneously preserves efficiency of workflow while
increasing the availability of consultative services and other value-
based practices.
Computerized Order Entry, Decision Support, and Protocoling
Computerized order entry for imaging services may help to
avoid issues related to insufficient, misleading, or illegible clinical
104 A.P. Kansagra et al. / Current Problems in Diagnostic Radiology 45 (2016) 101–106
information that often accompanies handwritten or otherwise
nonstandardized requests for imaging.69-71 Indeed, these systems
can aggregate relevant clinical data—referring physician contact
information and patient location, among others—from multiple
hospital systems and display this information in a standardized
format.69 Thus, implementation of a technology-assisted workflow
for clinicians may improve radiologists’ work efficiency by reduc-
ing the need for direct communication with clinicians or exces-
sively detailed exploration of patients’ medical records before
study protocoling or interpretation.
Coupling computerized decision support tools with computer-
ized order entry systems may amplify these benefits further. By
encouraging appropriate imaging utilization at the time of order
entry, these tools likely reduce the need for radiologists to interact
directly with clinical providers to modify or eliminate unhelpful
aspects of imaging evaluation. As an example, Rosenthal and
colleagues have developed and implemented a decision support
system that provides clinicians with a “utility score” based on
clinical indication in the form of an ICD-9 code.72 Following
implementation of this system, several major insurance carriers
agreed to eliminate required preauthorization for high-cost imag-
ing studies. Similarly, a system to alert referring providers to the
presence of a contrast agent allergy and suggest prophylactic
premedication dramatically increased the number of patients
who were appropriately premedicated without radiologist
intervention.73
Computerized order entry for radiologists in the form of
electronic study protocoling can also improve radiologists’ work-
flow. As with computerized order entry for clinicians, these
systems can effortlessly aggregate important patient-related data
such as serum creatinine, allergies, and cardiac pacemakers from
the EMR and implement automated safety checks related to
specific study types (eg, magnetic resonance imaging and cardiac
pacemakers) or pharmacologic agents (eg, iodinated contrast
agent and renal function). Moreover, recallable electronic protocols
may greatly expedite protocoling in cases where serial imaging is
performed, such as multiple sclerosis or lung nodule surveillance.
Integrated Ecosystem of Imaging Applications
Large efficiency gains can also be realized with a tightly
integrated ecosystem of clinical applications, including PACS,
EMR, radiology information system (RIS), voice dictation software,
electronic protocoling applications, teaching files, and image
postprocessing software.74 As an example, context integration
between PACS, EMR, RIS, and dictation software can allow an
entirely PACS-driven workflow that automatically opens the
patient’s information patient’s chart in the EMR and initiates
reporting of the correct case in the dictation software and RIS.
Similarly, an electronic protocoling system with single sign-on
login and automatic patient lookup in the EMR may allow
dramatically more efficient study protocoling than other, less
tightly integrated systems.75,76
This same approach may be useful for radiologists who are
asked to review studies performed at other facilities and stored on
physical media such as compact discs. When no defined workflow
exists, referring physicians may bring these CDs directly to the
radiologist, who must divert his or her attention from other
interpretive tasks to perform the time-consuming task of loading
images from the CD. Finally, these images must actually be
reviewed, often using one of the many cumbersome and often
limited software image-viewing applications provided on those
CDs. Instead, radiologists’ workflow efficiency may be substantially
improved using software designed to facilitate image importation,
such as LILA (LifeIMAGE, Newton, MA), or direct upload to PACS.77
These workflows unburden radiologists and allow images to be
reviewed in an application that is more suited to interpretative
tasks.
Scheduled Rounds
The frequency of in-person consultation between radiologists
and clinical practitioners has dramatically decreased with the
widespread adoption of distributed PACS. Today, most in-person
consultations occur sporadically, though some services—most
commonly neonatology and trauma surgery—advocate for or
continue to practice formalized radiology rounds as a means to
improve patient care.78 In this setting, radiologists’ workflow may
be improved by identifying a specific, mutually convenient time at
which radiology rounds will occur. This practice would allow
radiologists to address other clinical demands at a different time
so that they may meet their interpretative responsibilities while
also increasing their availability for regular consultation.
Workload Optimization and Balancing
Improved optimization of radiology workload can be achieved
by identifying high-priority cases to be interpreted before less
urgent cases, thereby reducing the number of incoming interrup-
tive communications from clinicians in need of results to guide
time-sensitive management conditions. Halsted and Froehle
devised an automated work queuing system to prioritize cases
based on patient medical acuity, wait time, psychological state,
and other factors to present a prioritized queue to radiologists and
demonstrated a nearly 28% increase in the mean time between
workflow interruptions.8
Improved balancing of radiology workload can be achieved
through more diversified scheduling of nonurgent examinations to
more fairly utilize radiologists scattered across different reading
rooms. If a disproportionate number of imaging studies on a given
day are directed to a single reading room (eg, a large number of
brain MRIs on a day that coincides with a scheduled neuro-
oncology clinic), it may lead to excessive workflow for a small
group of radiologists that can produce a backlog of studies
awaiting interpretation and corresponding increase in disruptive
communications from clinicians requesting results. In contrast,
scheduling nonurgent studies to minimize day-to-day variations in
imaging volume between separate reading rooms may permit
more predictable and easily managed workloads.
Embedded Radiologists
Recent efforts to “embed” radiologists near their clinical coun-
terparts may also affect radiologists’ workflow. A recent study
demonstrated wide variability in the preferred modes of commu-
nication between radiologists and clinical providers depending on
their physical proximity.79 Not surprisingly, embedded radiologists
were more likely to communicate in person and less likely to use
automated result notification systems. Nevertheless, it remains
unclear if this alteration in physical layout improves or hinders a
radiologist’s efficiency, as the concept of embedding radiologists
has been promoted because of the promise of adding value to
clinical care rather than increasing interpretative efficiency.
Conclusion
Disruptions of radiologists’ workflow occur commonly and
come from a wide range of sources, including phone calls, pages,
in-person consultation, coordination of care, and burdensome IT
tools. Other hospital-based specialties use different workflows
than that of radiology but have developed solutions to mitigate
 A.P. Kansagra et al. / Current Problems in Diagnostic Radiology 45 (2016) 101–106
workflow disruption that can inspire improvements in radiology.
Through process redesign and improved IT tools, radiologists can
streamline workflow to reduce the number of disruptions and
competing demands during the cognitively intense task of image
interpretation and can thereby facilitate the delivery of more
efficient and higher-quality radiological care.
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