Technology Differentiators: CT, RIS/PACS and Ultrasound
The Siemens Somatom Sensation 64 CT scanner is one of three scanners Alamance Regional Medical Center in Burlington, N.C., has installed to stay on the leading edge of cardiac CT imaging and keep referrals coming in.
While large medical hospitals, academic medical centers and health systems have traditionally been the earliest adopters for cutting-edge imaging technologies, community hospitals reap the benefits as the next level of adopters of imaging and IT to balance the needs of the community with delivering better patient care, controlling costs and increasing business and referrals.

It is clear that community hospitals are making an impact. There are about 4,900 U.S.-based community hospitals, according to the American Hospital Association (AHA). In 2007, these hospitals saw record profits, posting $43 billion in revenue compared to 2006—the largest single-year jump in margins in at least 15 years, according to AHA. Net revenue grew at 6.7 percent, while expenses grew 5.7 percent. In this article, we take a closer look at how smart technology investments are helping community hospitals to align business priorities, deliver quality care and keep a competitive edge.

CT expands service lines with more slices, lower dose

Early adopters are already reaping the benefits of the explosion of configurations and new software developments for the CT realm. But for community hospitals, the business-building benefits of buying the latest and greatest in CT technology isn’t a sure thing unless the referral base is onboard.

Step 1 is to know what types of physicians are ordering exams—as well as getting educated on exams that could offer further benefits. “It’s important to ping your referring physician base to get a good idea of what types of procedures are ordered to determine what kind of features in a new CT scanner to look for since it doesn’t make sense to go out and purchase the latest CT if you aren’t going to use it,” says Chris D’Angelo, director of imaging technology at Alamance Regional Medical Center in Burlington, N.C.

The 240-bed community hospital watches carefully the exam ordering patterns of its approximately 700 referring physician base. Based on the observations and feedback from the referral base, Alamance has expanded its service lines to include more cardiac procedures, such as coronary CT angiography (CCTA). The hospital, which performs about 110,000 imaging exams annually, has installed the Somatom Sensation 16 for bread-and-butter CT imaging, as well as the Somatom Sensation 64 and Somatom Emotion 64 CT systems—all from Siemens Medical Solutions. The most recent addition is the Sensation 64 for CCTA and all other vascular procedures.

Since installing the newest scanner, Alamance has seen procedure volume increase by a third more specialty exams, and the hospital has expanded its capabilities in the CT angiography realm. With a new cardiology group that has joined the organization, D’Angelo says this area is expected to be a big push for them. And what’s next on their wish list? A Siemens Definition Flash scanner, perhaps in 2010, for use in CCTA, due to the scanner’s speed and low-dose capabilities.

“We’re taking it step by step,” he says. “64 [slice CT] is a good choice for us as we enter the cardiac CTA market, but already we’re looking forward at 2010 and planning to expand our services.”

Alamance is not the only community hospital capitalizing on CT. The emergency department staff at St. Elizabeth’s Medical Center in Edgewood, Ky., has already seen an increase in the number of CT brain perfusion and CCTA procedures they are able to now perform thanks to the new Aquilion ONE volume CT from Toshiba America Medical Systems they installed six months ago.

“You have to have the best imaging and best radiologist reading it in order to get referring clinicians to listen,” says Jeff Dardinger, MD, director of the vascular imaging institute at St. Elizabeth’s. “Just adding the newest system is just background noise, since they are looking for something new that provides more value.”

New procedures that St. Elizabeth’s has added, which are replacing invasive procedures, include CT brain perfusion, CCTA, as well as dynamic CT imaging of the renal arteries—all the while attempting to deliver lower radiation dose to the patient.

He says since installing the system six months ago, “cardiac CT volume has increased and CT brain perfusion has taken off.” The hospital now performs approximately 40 to 60 CTs daily, and now, imaging has shifted to the ER, where it is more easily reimbursable. Also, they are looking at moving CT brain perfusion and CCTA to an outpatient setting, to better determine the need for hospital admittance. Dardinger adds that they are just beginning to measure changes in costs since the shift to the ER, and suspects the hospital will reap the benefits in the coming year.

RIS/PACS levels the playing field

With image management now more often than not an enterprise initiative rather than a department or facility mission, integration and connectivity among departments, facilities and systems are mission critical. To move images and reports around, community hospitals are looking for web-based RIS/PACS that can provide connectivity hospital-wide and remotely, to maintain a standard of care and prevent the migration of that care to larger facilities. They seek systems that implement easily and do not require huge IT commitments.

At Thibodaux Regional Medical Center in Thibodaux, La., the staff has capitalized on its investment in a NovaPACS web-based PACS from NovaRad purchased in 2003. The 120-bed hospital, which offers CT, MRI and nuclear medicine imaging services, annually completes approximately 80,000 imaging studies.

Web-based has been key to integration and connectivity among imaging modalities within the hospital and in areas such as surgery, endoscopy and cardiac cath labs, says Fernis LeBlanc, RT, PACS administrator, and Camile Richard, RT, imaging director.

“We interface with cardiology and are working to get echoes stored, EMGs, EKGs and are approaching surgery to store some endoscopy procedures in PACS to work toward an EMR,” LeBlanc adds. The PACS has an onsite, seven-year RAID 5 archive for storing images.

The hospital’s 100 active, on-staff physicians now connect to read and view images or look at reports from home or office, and referring physicians in other cities and states, have access to images and reports—a definite benefit since referring physicians help community hospitals keep volume up.

Report turn-around times have dropped, too. The hospital’s three-hour report turn-around time is a prime marketing feature for referring physicians of a rural community hospital faced with competition from four imaging centers.

“Referring docs are more interested in how quickly they can get a report back,” says Richard. “That was probably a competitive disadvantage for us before we implemented PACS. Now, it has helped us mitigate any loss we might have incurred and helped us be more competitive.”

At Morristown-Hamblen Healthcare System in Morristown, Tenn., Emily Blomenberg, director of Imaging, doesn’t have to look far to understand the competition from outpatient imaging centers. The 147-bed hospital, with an annual imaging volume at close to 80,000, has its own. Factors like increased access, decreased parking, longer wait times—all while maintaining a high standard of care—are a challenge. “But by focusing on customer care first and foremost, we can stay in the game,” Blomenberg says.

Two years ago, while considering a move to using a teleradiology provider, the hospital, which was dependent upon manual processes, quickly realized that it needed to invest in a technology that would enable that transition. They chose to invest in a RIS/PACS from Amicas, Blomenberg says.

“We wanted to bid for a larger imaging group to provide interpretations for us, and to do that, we had to upgrade our technology to allow us to be able to get images to them virtually for subspecialty access,” she says, adding that cost, of course, was a key consideration.

Morristown purchased the RIS outright but designed a pseudo-ASP (application service provider) model to pay for its PACS. The hospital houses all of its own hardware onsite, but pays for PACS on a per-exam fee. At the end of the five-year “lease,” the hospital will own the PACS outright.

Since the concurrent deployment, workflow at the hospital is more like that of an airport terminal, Blomenberg says. With Amicas’ RealTime Worklist, the staff get up-to-date, minute-to-minute views of what is going on in radiology, from both the RIS and the PACS. And, since space is a premium in a community hospital, the ability to have new space and draw revenue from it brings additional value, now that they no longer have to house film jackets.

“Many of us question how to maintain growth and revenue but still afford updated technologies and services and for many, the answer is simple—keep your local base coming to you,” Blomenberg adds.

Ultrasound: Image fusion and smaller systems with big capabilities
Ultrasound was the No. 1 imaging technology in which facilities invested in 2008, especially for portable, OB/GYN, echocardiography, 4D and 3D applications, according to Health Imaging & IT’s 2008 Top Trends Survey.

For Decatur Memorial Hospital in Decatur, Ill., new ultrasound equipment was certainly on its list of investments—the hospital purchased a Logiq E9 ultrasound system from GE Healthcare in October 2008.

“Since our goal is to provide any imaging services that you need without having to leave town, we have to have equipment that fits our community’s needs,” says Dave Overlot, director of imaging at the 300-bed community hospital that performs approximately 170,000 imaging exams annually, of which about 12,460 are ultrasound studies.

The key attraction to the Logiq E9 system was the capability to fuse ultrasound images with images from other modalities, like CT and MR, on various patient body types. With a GPS-like technology to track and mark a patient’s anatomy during the ultrasound exam, sonographers and radiologists can track hot spots found on previous CT, MRI or PET scans during a live ultrasound session, to confirm what is being seen on ultrasound is the same thing as what was previously found. Ultrasound fusion can be done even using a scan from five years ago.

“So if we find a hot spot on a CT or PET, we can mark that, download those images into the ultrasound. We scan the patient, find anatomical points that are the same, set the points and the CT or PET will move with your probe to confirm what you see on ultrasound [study] is the same thing on CT,” says Overlot.

It has great potential for guiding biopsies efficiently—a functionality of particular interest since the hospital currently performs a high number of CT-guided and MR-guided biopsies. Additionally, within the next year, they will be evaluating moving beyond use in the general ultrasound department, to using the system in the interventional radiology lab as well, and perhaps in the emergency department.

Expanding beyond conventional ultrasound is something that San Francisco Medical Center, part of The Permanente Medical Group in Northern California, is familiar with.

When it comes to technology investments, the primary focus is on improving health outcomes, and that includes imaging systems, says Chief of Radiology John Rego, MD. Kaiser runs statistical analysis on utilization trends and growth to figure out where to put new imaging equipment based by regional data and access problems within its member hospitals. It’s also true that the miniaturization of technology has shrunk high-end ultrasound systems into boxes that are far smaller than previous generations and enable far greater portability and flexibility. This evolution brings with it the need for a change in mentality that small doesn’t mean less performance, in fact, it means higher performance and multifunctional with the latest in ultrasound systems. Portable and high performance now are one in the same.

For San Francisco Medical, the quest to improve outcomes resulted in the deployment of several ultrasound systems from Zonare Medical Systems—the and ultra systems. “We have two flavors, a smaller cart for interventional areas and a larger ultrasound cart for radiology applications,” he adds.

The hospital was looking for small, portable systems for a variety of applications, from radiology to the ICU, ER and almost every subspecialty, since space is almost always at a premium, especially in the ICU. “Having a portable system that you can bring directly to the patient’s side really hits the mark,” says Rego.

Looking ahead

Community hospitals across the U.S. are leveraging investments in information and imaging technologies that help them keep business coming in while improving patient care and bettering referring physician experience with a variety of features and functionalities to save time and uncover unrealized revenues. And while economic uncertainty continues, hospitals are challenged with finding ways to succeed and at best, keep volume at an even level. Making a well thought-out and selective purchase best suited to fit the needs of the community and referring physician, be it RIS/PACS, CT or ultrasound or any other IT or imaging equipment, can be the leverage needed to carry you through to better days.