Until a few years ago, many of North Shore-Long Island Jewish Health System's radiology departments continued to operate partially or entirely on paper-based documentation systems.
Several years ago, North Shore-LIJ Health System, which cares for people of all ages throughout Long Island, Queens and Staten Island, established a strategy for information technology to implement enterprise solutions allowing for sharing of patient information across hospitals. In radiology, that has led to the installation of highly integrated, multi-vendor products which provide a robust and highly redundant technology environment.
That, in turn, provides clinicians with seamless availability to patient images and reports across the health system. At the core of this enterprise solution is the integration of Siemens' syngoWorkflow, Nuance's PowerScribe dictation system, GE's Centricity Enterprise PACS system, and EMC's enterprise storage solutions. This combination has been successfully implemented at most North Shore-LIJ hospitals, with the remaining sites scheduled for completion this year. Integration points also have been established with the Eclipsys Sunrise clinical information system for inpatients, while similar integration is being developed with the Allscripts EHR for ambulatory and outpatient environments.
The nation's third largest, non-profit, secular healthcare system, the North Shore-LIJ Health System's service area encompasses more than 5 million people. The winner of the National Quality Forum's 2010 National Quality Healthcare Award, the health system consists of 14 hospitals, 17 long-term care facilities, the Feinstein Institute for Medical Research, three trauma centers, five home health agencies, a hospice network and dozens of outpatient centers. In addition, North Shore-LIJ has partnered with Hofstra University to develop a new medical school. North Shore-LIJ's owned facilities house about 5,000 beds, employ more than 9,500 nurses and have affiliations with more than 7,500 physicians. Its workforce of about 38,000 is the largest on Long Island and the ninth largest in New York City.
By moving to PACS, multiple physicians and allied health professionals throughout the health system can now access a patient's study at any given time, eradicating the issue of many individuals vying to share one document.
The pain points
Until a few years ago, many of the health system's radiology departments continued to operate partially or entirely on paper-based documentation systems. There was a collection of disparate, site-specific systems with no automated sharing of patient information. Hospitals were still printing film, and technologists continued to handle paper requisitions, prescriptions, consent forms and intake forms.
As only one copy of a patient's exam was generally printed and multiple physicians might be referencing that copy, oftentimes a search was needed to locate it. When radiologists interpreted the study, they dictated the case into a system that was monitored by a team of transcriptionists, who typed the dictated reports. Finally, on a recurring basis, a courier picked up the studies to deliver them to a third-party warehouse for storage. Therefore, when a comparison study was needed to make a clinical interpretation, many times it required submitting a request to the warehouse and waiting hours or overnight for it to be available.
While a few hospitals had standalone PACS systems, it was only a partial solution. Long Island Jewish Medical Center (LIJ) and Southside Hospital (SSH) utilized the Siemens PACS solutions, whereas North Shore University Hospital (NSUH) utilized two mini-PACS solutions in their daily work flow: Merge e-Film for CT/MRI/X-ray and ALI McKesson for general ultrasound. Although these departments functioned somewhat electronically, they did not have all of the tools necessary to be effective.
According to Dr. Jesse Chusid, director of imaging informatics at North Shore University Hospital's radiology department, “e-Film had no automated work flow, so although we could view images at a workstation, we still used a paper-based system to determine which cases needed to be read. We were physically shuffling requisitions and other paperwork.”
The business case and deployment strategy
When it was decided to move forward with integrated enterprise solutions for radiology, it was agreed that those efforts would include RIS, dictation, PACS and image storage components, and that there would be an integrated product environment rather than a single vendor solution. While it was not a problem to justify a migration of individual site RIS and dictation systems to enterprise-grade solutions, the larger costs and efforts associated with installing PACS at all sites went through rigorous business-case analyses.
According to Chris Balbi, director of the PACS program in the office of the chief information officer, “the primary objective of the system's PACS strategy was to develop a budget model that included direct and indirect outlays, and identified the cost savings/ROI in order to provide a basis for project planning and development. A review of initial operational costs by site revealed significant opportunities for savings based upon the establishment and utilization of an integrated enterprise-wide radiology environment.”
As a result, strategic and tactical PACS roadmaps were developed to provide a phased PACS implementation plan that included recommended support activities (data center work, enterprise system upgrades, implementation of mandatory patches, hardware upgrades and disaster recovery/failover solutions), as well as recommended hospital facility improvements (network infrastructure improvements and deployment of computed radiography systems).
It was recommended that the health system move forward to firmly establish the infrastructure required for PACS development and implementation as defined in the imaging service line strategic roadmap. Balbi says that “the completion of the PACS implementation will provide the groundwork for enterprise-wide secure access to diagnostic images, rapid turnaround of imaging reports, virtual interpretation of images by radiology sub-specialists, overall improvement in customer satisfaction and greater opportunities for efficiencies and cost savings.”
It was quickly determined that Siemens' syngoWorkflow, and Nuance's Powerscribe dictation system, which had already been installed as stand-alone systems in several hospitals, would be the enterprise RIS/dictation solutions. At the same time, there were active product evaluations undertaken for PACS and the associated image storage solutions, which led to the selection of GE's Centricity PACS, and EMC's enterprise storage products.
Working with hospital and radiology service line leadership, a plan was developed to roll out this new integrated environment across the hospitals, with sequencing based on system-wide clinical and business objectives. That deployment included implementation and migration to the enterprise RIS/Powerscribe system at all hospitals, as well as the implementation of PACS. In addition to those core systems, the technical project also included related upgrades of the enterprise data network (to handle projected image traffic) and radiology devices (including the introduction of CR for non-digital devices). Beyond the technical, a key task to assuring success was the evaluation and modification of radiology work flow, including more standardized patient care practices and metrics of delivery.
As the project progressed, other related items, such as ambulatory radiology units, third-party teleradiology services and peer review functionality, have also been incorporated into the fuller picture of what is entailed in delivering radiology services.
A benefit of the integration between the upgraded RIS and PowerScribe is that the reports are available for review immediately after dictation. The radiologist can now sign off a completed report while viewing the original image, thus improving turnaround time on a patient's results. Naturally, any evolution of work flow is bound to have its quirks, and the integration between PowerScribe and PACS has been no different. Currently, there is not a mechanism for launching a study in PACS based on the selection of a report in PowerScribe. This is an issue at those hospitals where reports are often generated by residents and passed on to an attending physician's queue. Future enhancements to the resident work-flow features are expected to provide more flexibility to drive a report review from within PowerScribe.
The cost of the RIS, VRS and PACS software licenses, the necessary hardware associated with the enterprise storage solution and application servers, incremental network bandwidth and the need for additional information technology staff to operate and maintain each of these components offset the savings of an enterprise radiology system. However, far outweighing the financial investment is the increased quality of patient care the technology offers.
By moving to PACS, multiple physicians and allied health professionals throughout the health system can now access a patient's study at any given time, eradicating the issue of many individuals vying to share one document, as well as the problem of missing films. Radiologists also now have the ability to develop specialized work lists which route studies to the appropriate covering physician group. Factors like these have contributed to a more timely interpretation of studies. Since February 2007, NSUH's radiology department has seen nearly a 90 percent reduction in unread cases (defined as exams older than 48 hours which lack a final interpretation) and about 40 percent reduction in final report turnaround. At LIJMC, the radiology department has experienced an 80 percent reduction in final report turnaround time.
According to Chusid, at the onset of implementation there were a few bumps in the road regarding the system's stability and the limited capability of customizing or adapting the product to accommodate the needs of the user. While no single piece of technology is ever perfect, he says, having all health system hospitals linked in a “virtual reading room” allows staff “to provide scarce subspecialty expertise to community sites, which would otherwise make do without the full gamut of subspecialty radiology interpretations. This includes access to musculoskeletal, neuro, and thoracic fellowship-trained radiologists.”
An enterprise RIS/PACS/VRS also permits “greater flexibility in coverage and limits underutilization of physician resources, since cases performed anywhere in the health system can be accessed from any workstation,” Chusid says. “Radiologists at NSUH can help read cases at the Center for Advanced Medicine if they are short-staffed. In the evening, a single staff radiologist can cover both LIJMC and NSUH ED cases from his or her usual workspace.”
Since the deployment of the enterprise system, the radiology department has been able to cover emergency cases during evening hours, which typically would have been handled by an outsourcing company. Outsourcing services for this type of work would have cost approximately $750,000 annually for preliminary interpretations alone and nearly $1.1 million annually for the final interpretation.
Future expansion and enhancements
The future of North Shore-LIJ Radiology is expanding as the needs of the health system and patient community increase. Later this year, a third ambulatory imaging center is scheduled to open. There are also plans to implement digital imaging within several urgent care centers being opened. This requires that the enterprise PACS not only be integrated with Eclipsys Sunrise Clinical Manager for its inpatient EHR and the Allscripts Emergency Department Information System (EDIS), but also with the Allscripts Ambulatory EHR for its ambulatory settings and the LIPIX Regional Health Information Organization (RHIO). This RHIO will connect healthcare entities across Long Island to improve the quality and efficiency of healthcare for the region's patients and care providers by facilitating the exchange of clinical information without compromising privacy.
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