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 Special Feature

Filmless & Paperless

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   February 2010

HMT
Olathe's radiology/cardiology PACS team includes (front row, from left) Ralph Brewer, RIS coordinator; Lucretia Craig, chief imaging officer; (second row) Anish Mathew, PACS coordinator; Jason Hohman, imaging services information systems manager; Keith Pinney, information technology manager; Dan Eyler, radiology manager; (third row) Mike Shlenk, administrative systems manager; and Ron Galloway, non-invasive cardiology manager.

Olathe Medical Center overcomes technical, political and organizational hurdles to deploy one of the nation's first integrated radiology and cardiology PACS.

Many healthcare organizations advocate bringing cardiology and radiology image-management functions together, but the technology and challenges can be daunting. Olathe Medical Center was no different, but in the face of these obstacles, this Kansas community medical center had a vision of including each patient's images in a single patient jacket — one reliable image-management solution easily accessible from any PC, whenever required for patient care.

Olathe Medical Center proved up to the challenge, overcoming technical, political and organizational hurdles to deploy one of the nation's first integrated radiology and cardiology picture archive and communication systems (PACS) in 2006. The system was rolled out across a 300-bed facility and its network of more than 350 staff physicians.

"We no longer treat radiology and cardiology as separate from an imaging perspective," notes Lucretia Craig, chief imaging officer. "There is only one PACS as a fully integrated enterprise solution. We believe in one patient record. The world is moving in that direction, and it makes perfect sense to take imaging there, as well."

"As we increase our utilization of cardiac MRI and CCTA, it has been very helpful to be able to access the echocardiogram and cardiac catheterization images for correlation," adds radiologist Donald Stallard. "It has increased the efficiency of the read and, even more important, the reading accuracy, based on multiple comparisons."

Founded in 1953 as a 30-bed hospital, Olathe Medical Center has become a regional facility located on one of the largest hospital campuses in the Midwest — a 285-acre site in southern Johnson County, Kansas.

The five-year cost-of-service projection included savings on film and processing, but the primary objective was to improve access to information and enable safe, high-quality care.

This acute-care medical center averages more than 44,000 patient-care days per year. Its emergency-care center is one of the busiest in the region. The campus houses several centers of excellence, including Olathe Medical Center's Accredited Chest Pain Center, the Kansas Cardiovascular Center, Olathe Regional Oncology Center, The Birth Place and The Kansas Joint Specialty Center.

Caregivers at Olathe now have on-demand access to complete image data from anywhere in the hospital, as well as from remote locations via the Internet. The filmless, paperless system dramatically improved imaging and clinical work-flow efficiency, Stallard says.

Worth its weight in gold

"The superficial advantage is clearly the convenience of accessing all patient images in one location," notes cardiologist Kit Powers. "But on occasions when the cardiologist needs to access all information at one time to make a life-saving decision in a split second, the system has been worth its weight in gold. The process has also helped our group in creating a centralized reading approach to accommodate facilities and physician offices located off campus."

"An extensive work-flow analysis of each radiology department section was key to our success," Craig explains. "Through that process, the PACS implementation team acquired intimate knowledge of all imaging-related processes and gained the buy-in of staff in all areas."

The implementation included a phased rollout backed by tailored training for physicians, nurses and technologists. After going live, the PACS team provided around-the-clock support, including direct contact with the team 10 hours per day by way of a mobile telephone line.

Digital-image management was not new to the center, which already had a cardiovascular information system (CVIS) and a standalone cardiology PACS. The cath labs went filmless in 1999, and PACS for echocardiography was integrated in 2004, eliminating tapes for those procedures.

The hospital performs approximately 120,000 imaging studies per year. The fully integrated PACS archives MRI, CT, cath lab, electrophysiology, diagnostic radiology, digital mammography, DEXA bone densitometry, ultrasound, echocardiography and nuclear medicine studies.

Olathe Health System launched its integrated PACS project with a specific set of 10 goals — all achieved — aimed at improving the timeliness of care and enhancing services delivered. Based on these objectives, the team sought to create a secure system that would protect patients' privacy and comply with HIPAA, yet make images available easily and quickly to enable fast, accurate diagnosis and effective collaboration among all physicians involved in the patient's care. The ultimate objective was reliable, easy access to medical images from any device or procedure, anywhere in Olathe's organization. "The bottom line is that you can't afford not to deploy PACS in the world today," observes Craig.

After an exhaustive qualification and selection process, the team chose the Centricity PACS from GE Healthcare. According to Craig, Olathe started with the top 10-rated vendors and evaluated each based on annual cost, five-year cost of service, maintenance and implementation time. The five-year cost-of-service projection included savings on film and processing, but the primary objective was to improve access to information and enable safe, high-quality care with a system that was enterprise-capable and could grow with the organization. From this data, Olathe whittled the vendor list to the top three, conducted site visits, and then had on-site demos for the two finalists.

Work-flow analysis critical

Critical to the planning process was the detailed work-flow analysis. "We forced the deep-dive analysis of what was happening in every area, including the film library," Craig says. "A cursory work-flow analysis could have put the PACS go-live in jeopardy.

"We really don't have any issues today with our PACS — everything just works so well," she adds. "Analyzing work flow was a long, painful process, but we learned what we were doing today, and what we needed to do tomorrow. My advice to other sites is if they try to implement PACS fast and furious, without a complete work-flow analysis, they will experience pain with the implementation and, possibly, beyond. And would you rather have the pain on the front end, where you can work toward resolving it, or do you want it on the back end, where you may not be able to fix it?"

Film library work flow would remain important during the PACS deployment because during the transition period, radiologists still needed access to prior films for comparison, and the library staff needed to manage PACS images on CDs.

The Centricity PACS was deployed in stages: radiology department in 2006; migration of existing cardiology image data to the PACS followed by going live in 2008; and conversion to a paperless requisition system in 2008. PACS access was deployed to staff as well as physicians.

A "filtered" modality work list and multidepartment/multisystem storage-area network (SAN) are critical to Olathe's PACS, Craig says. Olathe filtered each modality by department and location, so each technologist would receive only the orders that are pertinent to their imaging system, without scrolling through a large master list of all orders. For example, ultrasound receives only those orders, and the emergency room receives orders only for the ER patient.

Olathe realized in 2009 that the SAN solution, originally deployed for PACS, could play an important role in helping the health system virtualize servers and applications across the enterprise. "The SAN solution actually promulgated our vision for virtualization," says Craig. "As we virtualize our servers, we are using the SAN as storage for servers across departments and facilities."

Workstations in interpreting physicians' offices enable fast, convenient, comfortable reading with attention to ergonomics and environment. In the emergency department, rapid access to images expedites emergent care. Cart-based workstations make images available in the operating rooms and ICU.

Access to images from anywhere

For hospital staff physicians, a Centricity PACS Web application provides access to images in the office or off site via Internet connections. The hospital supplied a cable connection, and the physicians installed the necessary routers and PCs. Adoption was quick and universal.

"Shortly after we deployed PACS Web, we had a case where a neurosurgeon was downtown celebrating the birthday of one of his children," Craig says. "He took his laptop along. During the birthday party, he got a call requesting that he report to the hospital for a head trauma case. Instead, he was able to view the patient's images on his laptop and determine that surgery was not called for."

At the staff level, workstations in imaging areas allow technologists to verify exams rapidly before sending them to interpreting physicians. A key strategy, Craig explains, was to place adequate numbers of workstations in locations consistent with the work flows so as to minimize technologist waiting. Meanwhile, PCs throughout the hospital were upgraded to meet Centricity PACS Web specifications. Now, nurses and physicians on the floors can conveniently access PACS from any PC on any desktop.

Extensive training was conducted for radiologists, staff technologists, ED physicians, referring physicians and film library staff. The training emphasized tools and techniques specific to the person's job functions, along with test runs with actual images. Referring physicians were invited to visit a dedicated viewing room at the hospital for training any time, day or night.

Support was provided by trained super users and representatives from GE Healthcare IT applications. Users also had access to instant support via a dedicated PACS help line.

A critical component of the transition to PACS was management of film-based images. "The film library's involvement was predicated on the fact that we would not be able to immediately shut off the manual-labor process of retrieving prior images," says Craig.

Prior images were pulled from storage and delivered to physicians, who placed them on view boxes if required. Eighteen months after going live, demand for film-based prior images had decreased to about two to three cases per day, greatly reducing manual labor and increasing radiologist efficiency.

Another challenge to PACS implementation was accommodating foreign PACS exams brought to the hospital on CDs. To ensure consistency in the imaging record, the hospital implemented a process of having all CDs delivered to the radiology department, where the data is loaded on a utility workstation and simply reburned with the Olathe exam and medical record data and the GE viewer everyone is familiar with.

Craig credits much of the hospital's successes to the rigorous work-flow analysis on the front end and to comprehensive staff support before and after going live. "A detailed analysis of imaging-related work flow gets everybody on the same wavelength," she says. "It was an emotionally draining and painful process, but the bottom line is that it cleared the obstructions from the road ahead as we went through the work-flow analysis and proved what the benefits of PACS would be."

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The PACS benefits

Before the PACS implementation at Olathe Medical Center, a diagnostic chest x-ray required 59 steps from acquisition to report delivery. It now takes seven steps. In addition:

  • Report turnaround time (RTT) has dropped from 18 hours to less than two hours.
  • Mammography RTT has been reduced from 48 hours to same-day performance.
  • Exams requiring rereading have been reduced from an average of 129 per month to six per month.
  • Duplicate dictations have been eliminated. Prior to implementation, Olathe estimated an average of 35 duplicate dictations each month.
  • The imaging department was able to reduce five full-time equivalents because of improved process efficiencies.
  • Anecdotally, Olathe has seen an impact on referrals, from nearly every-day multiple complaints, lost films and demands that were difficult to handle, to virtually zero complaints.
  • During the first year of the radiology/cardiology PACS implementation, Olathe realized more than $500,000 savings in film, chemistry and maintenance fees for equipment to produce films. In subsequent years, Olathe has seen an average of $300,000 in annual savings.
  • Physician satisfaction has also increased. A survey prior to the multidepartment PACS was 2.4 on a scale of 1-5. In 2008, the repeat survey yielded a 5.

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