PACS/RIS/Imaging - Drivers and Outcomes of PACS

The need for speed in delivering X-rays and diagnostic scans to staff and referring physicians is helping to drive adoption of PACS (picture archiving and communications systems) in hospitals that have traditionally relied on film-based radiology departments.

When healthcare facilities add a radiology information system (RIS) to their PACS initiatives, they not only can take advantage of feature-rich electronic medical records (EMRs), but they also can provide higher levels of patient care. In fact, raising the standards of patient care and streamlining workflow are two factors that figure prominently in the decision to upgrade to PACS.

“In the mid-1990s, we were looking for ways to visibly and dramatically improve our service to the community and, at the same time, to do so more cost-effectively,” says Howard Stewart, PACS/RIS manager at Southern Ohio Medical Center (SOMC) in Portsmouth, Ohio. “We realized that the potential lies within medical imaging. We wanted to get data to physicians when and where they needed it, so we decided to look at ways to share data electronically.”

Kathy Hood, director of radiology at AnMed Health in Anderson, S.C., says that while reducing costs per procedure and cutting costs associated with a film-based environment did figure into the decision to move to PACS, providing better healthcare by reducing turnaround time was the most important factor. The justification for investing in PACS was based on customer service and physician satisfaction. “Focusing on cost savings is not enough. It’s the ability to provide real-time radiology. The real key to a successful PACS is workflow. It’s all about workflow and speed,” says Hood.

But to be truly successful, PACS also must be pushed to every corner of the enterprise so that all physicians, regardless of location, can access images. At the University of Virginia Health System (UVAHS) in Charlottesville, Va., providing this kind of blanket access has been a key component of its PACS strategy. “Enterprise is not just ‘playing nice’ in radiology or just within the hospital,” says Sean Moynihan, director of information systems in the department of radiology. “It’s taking care of all the clinics and referring physicians. That’s thinking enterprise. We’re thinking not just radiology-based systems, but also those in other areas like ophthalmology, digestive health and urology, as well as clinics and users beyond the walls of UVA—even beyond the city of Charlottesville.”

Clear-Cut Strategies
At each of these institutions, rolling out a PACS was part of a clear-cut IT strategy. At the 232-bed Southern Ohio Medical Center, for example, referring physicians had to wait 20 hours or more for radiology reports, while physicians in the emergency and surgery departments wanted access to films at any time.

In addition, SOMC was planning to build a new intensive care center and a full-service emergency center, making the need for immediate access to films more critical. Since digital images are easier to distribute than hard copies, the hospital began the search for a PACS in 1996.

Out of four vendors, the search was narrowed to Agfa and one other large vendor, mostly because both supported Sun- and PC-based platforms, and SOMC, at the time, was using only Dell and Compaq computers, Stewart says. But he also notes, “Agfa offered a pretty comprehensive product, even in 1997.”

In August 1998, SOMC signed the contract and went live with Agfa’s IMPAX in November, installing a centralized archive and two portable CR units in the ER and ICU. With physician support growing, SOMC’s radiology department soon went online with PACS and, in February 1999, installed Agfa’s Web distribution system, which provided physicians who were not on the main hospital campus with access to diagnostic images via dial-up service.

In early 2000, two SOMC satellite centers that offered imaging services also went online. Since then, the hospital has further expanded its offerings by upgrading to the client/server-based IMPAX 4.5 and the Web-based IMPAX Web 1000, which permits up to 200 users to access the system at the same time.

Decisions for the Long Term
Although PACS is now used as the sole method for reviewing and archiving medical images, its use by radiologists evolved gradually, says Luis Marquez, SOMC’s administrative director for medical imaging. “They continued to read ultrasound on film for a long time. But we started X-rays in 1998, CTs in 1999, MRIs and nuclear medicine in 2000 and then ultrasound.”

In a way, installing a PACS was just another step in the radiology department’s own evolution. The hospital already had a RIS, although it was a homegrown version that was developed in 1986, Marquez notes. Subsequently, SOMC purchased a commercially available system, but Marquez says it was not GUI-based, did not offer HL7 interfaces and was not expandable. If the organization had decided to stay with it and support it, “it would mean changing our entire platform,” says Marquez. SOMC wasn’t willing to do that. Then, “Agfa approached us to participate in beta tests and clinical trials,” he continues. Currently on the second beta version, SOMC was scheduled to go live with Agfa’s RIS last month.

Interestingly, Stewart says this particular RIS was already available in Europe, but it had to be updated for use in the U.S. to comply with HIPAA and the Sarbanes-Oxley Act of 2002.

Like SOMC, AnMed Health had been using a stand-alone RIS, according to Hood. But the current RIS will soon be replaced by GE Medical Systems’ Centricity RIS product, which will provide an integrated RIS/PACS solution. “The RIS is currently in a test environment,” she says. “We’re preparing all interfaces and connectivity necessary for implementation next month. This integrated platform was not available when we initially purchased a PACS in 2001.”

Even though the radiology department already had set its sights on PACS, it proved to be an enterprisewide effort. PACS was a radiology project, but it was justified as part of an overall IT strategic initiative, Hood says.

In an effort to move toward a paperless environment, the organization rolled out an EMR prior to PACS. The fact that referring physicians were already utilizing computers for EMRs provided a much smoother transition to electronic image review via PACS.

Luis Marquez (left) and Howard Stewart of Southern Ohio Medical Center

Tim Catoe, the PACS manager, adds, “We made a decision to become a PACS department and stayed focused on that goal. It is important to stay focused and not revert back to film during PACS implementation.”

The decision to go with GE came at the end of a four-year search, Hood says. “We narrowed it down to two vendors. We had utilized one of the two for

30-plus years as our film vendor. However, we chose GE primarily because any questions we asked, GE brought the answers to the table, proving that they wanted to partner with us in this major endeavor. In addition, they provided a PACS solution that met our current needs and also presented us with a road map for the future.”

The system’s platform garnered support from the physicians, who also found its tools more user-friendly, Hood says. “There was no resistance. They truly embraced PACS.” The hospital rolled out GE’s earlier version, called PATH SPEED, in November 2001, then upgraded to Centricity 2.0 in October 2003.

Challenges of Due Diligence
At UVAHS, implementing a PACS was a little more complicated, but eventually it proved to be successful. Matthew Bassignani, M.D., associate professor of radiology and the medical director for radiology information systems, admits that in 1994, a few years before he came to UVA, the hospital attempted to adopt an early version of a PACS. However, while it required a sizable investment, the technology was not mature enough to do what everyone hoped. Years later, when the proposal was made to start looking for a workable PACS, Bassignani says the hospital’s administration was “a little skittish.” But by then, the technology had significantly changed, he notes.

In the process of making its intensive care unit MINIPACS Y2K-compliant, UVAHS upgraded to a new PACS and installed the client/server Web-based MediSurf, a PACS from Algotec Systems Ltd., which was part of the Imaginet product line and provided digital images to both the ICU and ER. At first, the system was used only to distribute chest X-rays on CR, Bassignani says, but then the department began sending CT scans, ultrasounds and, eventually, MRIs. “We threw everything we could at it,” he says. Algotec’s system proved so successful that Bassignani says it became evident that it was “time to look for an enterprisewide system.”

In 2000, UVAHS evaluated products from a number of vendors including Algotec and three other, large suppliers. “People thought we were crazy to consider Algotec, because it was a small provider,” says Bassignani, “but after a year of due diligence, Algotec won. They were as nonproprietary as any database could be. With other vendors, we worried that their technology was so proprietary, we could get locked into using it. MediSurf Imaginet was straight DICOM in, DICOM out. Plus, they were willing to work with us. They got the benefit of our intellectual capital to make the product better, and we got the benefit of their flexibility.”

Costs and Dueling Platforms
In November 2003, Eastman Kodak Co. acquired Algotec Systems Ltd., and the MediSurf Imaginet product UVAHS had installed was renamed Kodak Directview PACS. Rather than investing in a new RIS, UVAHS decided to keep the one it had purchased from Siemens and created an HL7 interface between the two systems.

The ability to write interfaces between two systems also underscores the extent to which single-source solutions are claimed to be “integrated” and the challenges faced by healthcare organizations that choose proprietary technologies. “We tell vendors, ‘You need to support other peoples’ PACS as fully as you support your own,’” says Bassignani.

Adds Moynihan, “Single-source systems are very proprietary—hence, the foundation of the IHE (Integrating the Healthcare Enterprise) technical framework. With approximately 5 percent of the marketplace only having a single-vendor solution in place, IHE makes sense. What vendor is willing to give up the other 95 percent? IHE fills in the gaps that DICOM and HL7 left out. But in three years, a lot of strides have been made.”

“Focusing on cost savings is not enough. It’s the ability to provide real-time radiology. The real key to a successful PACS is workflow. It’s all about workflow and speed.”

— Kathy Hood
AnMed Health

Bassignani also raises the questions of cost and the ability of many small hospitals to pay for a single-source solution. “Not a lot of hospitals are going to dump their RIS and buy a whole new integrated system,” he says.

Then there’s the question of dueling platforms, says Moynihan. “How does a referring hospital send us their data? If they’ve got GE and I’ve got Kodak, they send it on a CD.” However, he notes that CDs created on a proprietary system used by one organization may not work with the system used by a second organization, or may crash the second organization’s system. To avoid that happening, image CDs that are received from other hospitals are viewed at UVAHS on “non-network PCs,” Moynihan says. “This is not optimal, but it prevents us from having to constantly ‘repair’ the workstations after a physician installs a conflicting piece of software from the CD.”

On the other hand, the nice thing about a CD produced on the Kodak system “is that it does not put an applet on your PC and thus does not impact other programs,” he adds.

Net Gains
As a 675-bed, university-based tertiary care hospital, UVAHS gets referrals from Virginia, North Carolina, Tennessee and West Virginia. It performs approximately 350,000 exams per year and has 32 staff radiologists, 30 residents and about 15 fellows.

As part of its investment in the Kodak PACS, the hospital also installed two RAID EMC 8730s, providing a total capacity of 15 TB of online storage. In addition to six specialty workstations that provide 3-D imaging, UVAHS also has 35 diagnostic workstations, each with two to four panel monitors and a 3 to 5 megapixel resolution. The PACS can transmit images to all clinicians throughout the institution and to those at home via a secure virtual private network, Bassignani says.

The hospital has given a PACS account “to every attending physician, affiliated, staff and resident, to third- and fourth-year medical students and to nurse practitioners,” he adds. “We have between 1,400 and 1,500 clinicians using the system, and all access is managed by the hospital’s IS.

“A very nice feature of our PACS is the LDAP (Lightweight Directory Access Protocol) functionality,” he continues. “They use the same user ID and password as their e-mail. With LDAP, when a user changes his e-mail password, his PACS password also is changed.”

Bassignani points to the PACS ability to allow clinicians in different rooms to view the same images. “With film-based systems, no two people can have the same image at the same time,” he says. “Nowadays, I simply get a call from a clinician and he says, ‘Hey, Matt, what do you think about … ,’ and we discuss the case while we view the images from our individual work areas.”

The successful integration of PACS into the delivery of healthcare at UVAHS becomes evident in those rare moments when access to images is not instantaneous, notes Bassignani. “If we have a burp in the system and it’s unavailable for a few moments, we hear about it loudly from clinicians.”

The successful implementation of PACS at SOMC can be seen in the amount of money and usable space this hospital has saved. The workhorse of Agfa’s IMPAX system is the EMC Symmetrix enterprise storage system, which provides about 42 TB of raw storage, Stewart says. Since all images are now stored digitally, about 1,700 square feet of floor space has been reclaimed, and the hospital was able to reduce its film library work force from 15 full-time employees to nine.

Marquez says that just the savings in film costs alone amounted to about $750,000 over three years, and that this money was put back into the budget to be used for infrastructure upgrades.

Adds Stewart, “We had planned an ROI of five years, but we actually saw that after two to two and a half years.” Nevertheless, he says, going completely filmless and paperless is proving to be a gradual process.

Agfa’s IMPAX 4.5, which is a client/server application, has a second distribution system that is Web-based. Out of a staff of 120 physicians, about 70 use the Web-based application, and between 20 and 25 are regular, everyday users, he says. But because many of the systems at SOMC are still paper-based, like patient and clinical documentation and physician order entry, “we do not have widespread use of physicians ordering directly into the system.

“We believe we’ll still have paper coming from doctors’ offices,” Stewart continues, “but in the hospital, we want to go paperless in about a year.” As an added incentive, SOMC is now evaluating various EMRs and is planning a total conversion within two years to five years.

Lost Films Are a Memory
Like SOMC, AnMed Health realized real savings almost immediately. “In the first year, we reduced our film budget by $260,000,” Hood says. Because AnMed Health has paired its GE Centricity PACS with IBM’s FastT storage server system, the hospital also was able to reclaim floor space in both its short-term and long-term file rooms. “We reduced the size of our short-term file space by 50 percent and now house no film in that area,” says Hood, adding that the hospital was able to create from that saved space an employee area and an office with three cubicles.

Similar space savings were realized in the third floor “penthouse,” which contained about a quarter of all stored images. That file space is now being used by the pharmacy and cardiology departments. Plus, five full-time file clerk positions were eliminated through attrition or relocation, and the ones that were retained were upgraded from file clerks to image librarians.

But more importantly, the hospital was able to see marked gains in efficiencies. With a little more than 250 staff physicians, the hospital does about 13,000 exams per month, says Catoe. “Our radiologists read 84 percent of all exams, and their productivity has improved by 54.6 percent.”

There’s also little chance that images will be misfiled or misplaced, says Hood. “We simply do not lose films anymore. With a manual film process, hospitals have to deal with the possibility of lost film. But with an electronic system, lost films are just a memory.”

Richard R. Rogoski is a free-lance writer and contributing editor to HMT. Contact him at rogoski@aol.com