Knowledge to facilitate care is the objective of healthcare. And technology is the means to acquire, build, communicate and mine that knowledge. The choice of which technology building blocks are right for each healthcare facility is a topic of near-constant debate, strategy, diligence and business planning. But not all solutions pack an equally strong punch, and not all healthcare facilities want and need the same technologies. The right technology at the right time deployed with the right infrastructure can deliver the medicine that healthcare needs—impressive efficiency gains; earlier, more accurate diagnostic data; accelerated patient care and reduced costs. One winning solution is RIS/PACS, saving sites like Alamance Regional Medical Center in Burlington, N.C., $500,000 annually. Similarly, speech recognition software slashes report turnaround to a bare minimum, with many sites delivering preliminary results in 10 minutes.
With competition for patients and providers at an all time high and budgets coming under the hatchet, radiology departments need to focus on solutions like these that improve efficiency and the bottom line to provide a competitive edge.
As 2008 winds down, we’re examining the year’s top technologies as identified by our readers, visiting with seasoned users across the country to discover how they’ve tapped into top technologies and what they’ve gained in the process. The critical technologies of this year and next run the gamut from imaging solutions to IT. On the modality side, Health Imaging & IT readers cite DR, breast MRI, CT and ultrasound as the year’s most important imaging solutions. Data storage, RIS, speech, cardiology PACS, advanced visualization and IT integration top the IT list.
Cardiac CT: The paradigm shift
Since bursting onto the imaging horizon in 2003, cardiac CT has seen tremendous technical progress in scanner configurations and software development. Yet the paradigm for diagnosing coronary artery disease has remained relatively unchanged. Patients aren’t identified or treated until they become symptomatic. What’s missing is a mechanism to identify asymptomatic patients with occult coronary disease so physicians can initiate aggressive therapy to prevent morbidity and mortality. What’s more, first-generation cardiac CT limits physicians to anatomy, detecting blockages, but not determining physiological significance. Cardiac imaging’s newest volumetric CT weapons re-invent the cardiac paradigm.
The Cardiovascular Research Institute at Washington Hospital Center in Washington, D.C., a beta site for Philips Healthcare 256-slice Brilliance iCT scanner, is investigating the potential of the latest CT technology. One primary question asks what volumetric scanners offer over their 64-slice peers. Do they open the door to scanning of asymptomatic patients?
“The problem with 64-slice CT is radiation dose,” says Guy Weigold, MD, director of cardiac CT. It’s in the range of other cardiac scans, but remains somewhat high. Consequently, sites need to be somewhat selective about referring patients for cardiac CT and limit scans to symptomatic patients who require an investigative workup.
Volumetric CT solutions deliver advances that may make it possible to extend cardiac CT to asymptomatic patients. Systems like Philips Brilliance iCT and Toshiba America Medical Systems AquilionOne slash scan time to a few seconds, imaging the heart in a single heartbeat, which means image quality is less likely to be degraded by cardiac changes during the scan. “It better freezes the heart and improves image quality,” sums Weigold.
St. Elizabeth Medical Center in Edgewood, Ky., has seen new doors opens since installing an AquilionOne in July 2008. “The biggest advantage of the AquilionOne is single heartbeat imaging,” says Jeffrey Dardinger, MD, director of vascular institute imaging. By imaging the heart in one rotation, the system improves temporal resolution and image quality, which improves on current cardiac CT and makes possible cardiac perfusion imaging. “We can watch cardiac blood flow and determine if a blockage reduces blood flow to the myocardium,” explains Dardinger. Equally important, higher slice solutions reduce radiation dose.
As researchers gather data, they are refining scanning protocols for new systems. Some sites leverage shorter scan times to streamline operations. A typical 64-slice scan patient requires beta blockers, which stretches the scan appointment to one hour and requires a separate room for IV administration and heart rate and blood pressure monitoring. Because very few patients require beta blockers with higher-slice scans, appointment time drops to as short as 20 minutes, decreasing the staff burden and increasing patient throughput. “It’s possible to complete 15 studies a day without beta blockers, and there is less work and prep for staff,” sums Weigold.
Other CT solutions achieve similar outcomes via a different model. Siemens Healthcare Somatom Definition DS delivers increased temporal resolution, helping sites improve throughput and accelerate patient care. “Cardiac CT helps reduce triage to disposition time,” shares Harold Litt, MD, chief of cardiovascular imaging at University of Pennsylvania School of Medicine in Philadelphia. In fact, the hospital reduced average ER triage to disposition time from 23 hours with cardiac stress testing to seven hours using cardiac CT imaging.
Litt and his cardiac imaging colleagues also point to a need for improved spatial resolution. One reason behind the drive for improved spatial resolution is calcium, says James Min, MD, director of cardiac CT lab at Weill Cornell Medical College in New York City. Current-generation imaging does not discriminate between stenoses by the percent of blood flow blocked. “This problem is only fixed by improved spatial resolution,” Min says. Weill Cornell recently upgraded from the GE Healthcare LightSpeed VCT XT to LightSpeed CT750 HD; HD 750 improves spatial resolution to accurately quantify stenosis in coronary and vascular vessels.
Imaging modalities on the move
While higher slice-count CT burst onto the scene in late 2007, other imaging modalities have gained traction in a more gradual fashion. Standouts, according to Health Imaging & IT readers, are handheld ultrasound, DR and breast MRI.
In the era of incredible shrinking budgets, solutions that provide a favorable price-to-performance ratio merit a close look. Hybrid ultrasound systems that convert from a standard, cart-based system to a handheld unit deliver a one-two punch that meets both clinical and business needs.
The radiology department at Swedish Covenant Hospital in Chicago invested in Zonare z.one ultrasound two years ago and uses it for mobile studies in the ICU and CCU—rooms crowded with respirators and monitoring equipment. “It’s challenging to transport a large machine to the ICU. Z.one is easy to maneuver and boots up fast,” says Bruce Silver, MD, chairman of radiology. What’s more, outpatient throughput is not interrupted because the department does not need to remove a system from service, which boosts efficiency while improving service to hospital departments. Radiologists use the system for a host of applications including biopsies and line access. “The common theme,” says Silver, “is that we are comfortable with its image quality to use it for a wide variety of applications.”
Other top imaging technologies represent a larger shift in operations. Nearly a decade after its initial launch, DR is demonstrating its brawn and delivering on its efficiency promise. When Springfield Clinic in Springfield, Ill., opened a new clinic in 2006, it decided to invest in DR for optimum efficiency and throughput, says Frana Evans, director of radiology. Orthopedic surgeons comprised the primary target.
Initially, physicians were skeptical about the promised gains. Many had lived through CR implementations at local hospitals. Not only had CR projects failed to increase efficiency but also created headaches with printers unable to accommodate the image magnifications orthopedic surgeons depend on.
Evans held the course, confident that DR could deliver the 10-minute turnaround time physicians required. The clinic installed Carestream Kodak DirectView 7500 and DirectView 9000 systems, locating the new DR rooms in the center of the orthopedic area. The system performed as promised—delivering five minute turnaround within weeks of deployment.
One advantage of DR, beyond the efficiency linked with the elimination of film and film handling, is anytime/anywhere viewing. Springfield Clinic makes images available via centrally located viewing stations and on portable tablet computers. In many cases, physicians access images before the patient returns to the room, boosting physician productivity and patient satisfaction. In other words, DR supplies maximum efficiency.
Efficiency isn’t the only driver behind tech adoption. In some cases, clinical service rules. 2008 saw a boon in breast MRI technology installs largely due to American Cancer Society (ACS) recommendations for screening high-risk women with breast MR taking hold, and studies showing breast MRI carries clinical benefits for diagnosed patients as well. The unique needs of the patient population, however, can be a hitch for sites that want to initiate a program.
Most breast MRI providers offer a multi-pronged program. Take for example Moffitt Cancer Center in Tampa, Fla. The center launched its breast MRI program in 2002 and used a 0.5 T magnet to aid treatment planning. Breast Care Specialists in Atlanta, Ga., realized a profound impact immediately after deploying an Aurora Imaging Technology Dedicated Breast MRI System in 2005. “Now surgeons won’t operate without breast MRI if they can avoid it. It has changed the surgical approach from lumpectomy to mastectomy in a number of cases,” reports Pamela Donlan, MD, radiologist. That’s because the MRI exam may reveal disease not detected on a mammogram, or it may indicate contralateral disease.
When ACS issued its screening guidelines, many breast MRI providers saw volume grow. Between 2002 and 2005 monthly volume at Moffitt Cancer Center rose from 25 to 100 patients and the center deployed a GE Healthcare Signa Vibrant to better accommodate patients. Similarly, Breast Care Specialists recently deployed a second Aurora system to ensure that it could accommodate increasing demand.
Experienced providers stress that breast MRI poses some challenges. “Patients are anxious,” says Lynne Hildreth, executive director of lifetime cancer screening and prevention at Moffitt Cancer Center. “Staff should be cognizant of their anxiety, and the facility and processes should be designed to be patient-friendly, comfortable and private.” Both technologists and radiologists need breast imaging background to provide optimal patient service. Moffitt Cancer Center draws on mammographers and trains them for breast MRI review rather than using MR generalists. Reimbursement presents another issue as pre-certifications can be time-consuming. Breast Care Specialists dedicates 2.5 FTE to pre-certification and scheduling of 15 to 20 daily exams. Finally, sites need to consider MRI-guided biopsy capabilities. It’s important to offer MR-guided biopsy on the same magnet as the original scan. Otherwise, patients may need to be referred to another site for the biopsy, resulting in delays, anxiety and inefficiencies.
Speech touts multi-dimensional gains
Health IT proponents claim technology can both cut costs and improve patient care. A handful of solutions fit the bill. Take for example speech recognition. North Shore University Health System in Chicago turned to Nuance Communications Dictaphone PowerScribe in 2007 to improve service to referring physicians and close the communication loop. The health system not only achieved its primary goals but also saved money in the process, says Jonathan Berlin, MD, associate professor of radiology at Northwestern University in Chicago. Similarly, Scripps Memorial Hospital in La Jolla, Calif., realized a marked increase in physician satisfaction after deploying MedQuist SpeechQ for Radiology primarily because the solution allows radiologists to release preliminary results immediately after review.
Traditional dictation workflow seems convenient for radiologists. Most dictate, correct and sign reports in a batch at the end of the day, resulting in 24 to 48 hour or longer turnaround time. Speech recognition permits an accelerated model that spreads reporting throughout the day and posts results immediately. Tight integration among PowerScribe, Epic EMR and Cerner RIS at North Shore makes reports available via the electronic patient record within 10 minutes.
The process accelerates and improves patient care by consolidating findings in a single document. Take for example an emergent pulmonary embolism ruleout. In a conventional workflow, the radiologist completes a preliminary read and the ER releases the patient if no embolism is found. It’s not uncommon, however, for the radiologist to detect secondary findings like a pulmonary nodule during the final read. The process is fraught with problems. “The finding could get lost in the shuffle,” says Berlin. And the ER needs to deploy staff to re-track the patient to communicate the additional finding. A well-integrated speech recognition solution does not separate acute and secondary findings, so physicians receive all recommendations and findings in one timely report.
Integration played a major role in Scripps’ decision to deploy SpeechQ for Radiology. SpeechQ delivers all information in a single screen, which means users can view history, comments and patient data in one location and import data right into the final report. The net result is increased efficiency and patient safety, say Kris Van Lom, MD, a radiologist at Scripps Memorial Hospital.
One of the primary challenges with speech recognition is compliance. Many radiologists are reluctant to transition to speech or self-edit because they believe it will slow workflow. The majority, however, do comply because they realize speech drives improved service and care. “The financial, operational and service benefits outweigh any productivity issue in many cases,” states Berlin.
Scripps and North Shore, for example, both report compliance in the 70 to 80 percent range. Both sites facilitate productivity with macros or templates that build standard normal or standard abnormal reports. With a template, the radiologist clicks on the area that differs from the template and dictates an impression. Compliance fuels cost-savings as the more radiologists comply with self-editing, the greater the cost-savings. Looking ahead, as speech engines improve accuracy to 99 percent, pioneers anticipate improved compliance and greater cost-savings.
The integrated enterprise
IT integration is a game changer in radiology as well as across the healthcare enterprise. Integration takes many forms. RIS/PACS, enterprise advanced visualization and integrated storage all fall under the integration umbrella. Each packs a punch. And in a tight fiscal climate, widespread results are critical. Alamance Regional Medical Center weighs investment against six core categories of commitment: safety, service, efficiency, quality, people and growth. Siemens integrated syngo Imaging PACS and syngo Workflow RIS produced gains in each area, says Preston Hammock, Alamance vice president.
Three years ago, the center sought to tap into the benefits of digital image management via an enterprise PACS project. As key stakeholders researched the technology, they realized integrated RIS/PACS represented a superior alternative. “The initial goal focused on eliminating film, but we wound up redefining radiology—reinventing workflow, cutting costs and increasing efficiency for staff, radiologists and patients,” shares Hammock. Patient care is faster and more responsive, and turnaround time is minimal with the integrated implementation.
On the radiology side, workflow is streamlined and integrated. Syngo automatically populates the worklist to reflect daily workflow; prior studies are linked to provide quick comparisons, and voice recognition enables quick sign-off. The gains accumulate downstream.
Take for example film-based ER imaging workflow. The process of developing, printing and documenting film images required a 12- to 24-hour turnaround. In contrast, digital images are immediately available in the ER, enabling informed preliminary results within 15 minutes and final results within 30 minutes for most patients. More efficient workflow translates into more direct patient care, says Hammock.
The center has realized additional impressive gains, saving more than $500,000 annually stemming from reductions in film costs and reduced FTEs in transcription and the file room. At the same time, imaging volume has increased by 14 percent. “We would not have been able to accommodate growth without integrated RIS/PACS,” states Hammock; however, the recipe for workflow success transcends RIS/PACS. At Alamance Regional Medical Center, the fully integrated desktop incorporates everything the radiologist needs to report and diagnose patients: RIS/PACS, syngo Voice for transcription, syngo Webspace for 3D and nodule detection and PET/CT capabilities.
The integrated RIS/PACS model works on the imaging center side, too. Carolina Regional Radiology, a full service imaging center in Angier, N.C., recently deployed Aspyra AccessRAD RIS/PACS as a springboard to the highly efficient filmless/paperless radiology model.
Other image-intense departments also tap into integration. The Heart Center at Duke University Hospital and Health System in Durham, N.C., first deployed echo PACS in the early 1990s, and for the next decade used a modality-centric approach to cardiac image storage, investing in separate PACS for various cardiac imaging modalities. Two years ago, the Heart Center decided to apply an enterprise image management model in cardiology with Philips Healthcare Xcelera as the cornerstone of the new model.
The model delivers a number of key benefits, says James Tcheng, MD, medical knowledge architect. For starters, it facilitates efficient, patient-centric clinical workflow by consolidating patient data. When a physician opens a report with images in the EHR, PACS opens the images in a few seconds. Online viewing also allows cardiologists to view images from other institutions to provide instant consults.
The Heart Center plans to use Xcelera as a springboard into a future that incorporates multi-modality image acquisition and manipulation, or super-imposing multi-modality images to create a 3D dataset. Currently, electrophysiology staff use a prototype to synthesize datasets from different locations. “This leads to shorter procedure times and better patient outcomes,” says Tcheng.
2009 will see a greater emphasis on the enterprise image management model. “At the end of the day, the advantages are tremendous. We’re entering an era where budgets are shrinking. Enterprise image management saves money and time and provides economies of scale,” sums Tcheng. One key economy comes on the storage side. Duke Heart Center, for example, replaced multiple disparate storage systems with a 60 terabyte storage area network (SAN).
Taming the storage beast
Nearly every healthcare enterprise struggles with data storage. Demands are increasing exponentially, yet space and staff are tight. Further exacerbating the problem is the specter of IT disaster. As enterprises become more dependent on paperless solutions, the need for comprehensive disaster recovery grows. Tackling the storage challenge delivers multiple benefits from enhanced service to improved disaster recovery.
Sheer necessity often drives sites to the data storage drawing board. Take for example Cancer Treatment Centers of America (CTCA) of Chicago. Three years ago, the enterprise started to transition from best-of-breed applications to a platform-based approach. The change in strategic direction provided an opportunity to fix the ailing storage environment, says CIO Chad Eckes. “The move to 100 percent electronic clinical documentation brought our dependence on data to light,” recalls Eckes. CTCA’s first-generation direct-attached system offered minimal control over storage, and the tape backup process represented a cumbersome burden on IT staff.
In 2007, CTCA invested in EMC Corporation Clariion SAN and an offsite data center, duplicating data every 15 minutes. A July 2008 upgrade to real-time replication provides additional security; however, the center maintains a multi-pronged approach to ensure 99.999 percent availability. The top level clusters and mirrors the production system, followed by live duplication at the data center. Next, disks are backed up on EMC Disk Library and final backups are on tape. Using multiple layers with different types of technology provides optimum insurance and recovery speed while keeping costs low. Another critical advantage comes on the operations front as the SAN approach allows CTCA to manage a rapidly growing storage environment with minimal staff. “If we had continued to operate our previous storage system we would have needed to double staff from two to four FTEs,” says Eckes. The benefit that matters most, however, is service. “The major benefit of this approach is insurance,” states Eckes. “It helps us keep our promise to our patients [by ensuring rapid access to clinical data].”
Storage is a unique project for each enterprise. Applications should drive the storage strategy; that is, storage is designed around clinical needs. Like CTCA, Genesis Health System, a four-hospital health system in Davenport, Iowa, started migrating to SAN after upgrading clinical systems. The storage system combines Hewlett-Packard EVA SAN with an HP NAS for medical archiving and document imaging. Cardiology and radiology data are consolidated on the SAN for six to 12 months of short-term storage with a Sun ASM providing the long-term archive. A divide-and-conquer strategy facilitates redundancy. Critical applications are split between data centers at two separate campuses and HP Continuous Access replicates data for additional security, says Dave VanDerHeyden, storage director.
Advanced visualization across the enterprise
“We should be leveraging advanced visualization as a next-generation PACS application,” opines Rasu Shrestha, MD, medical director of digital imaging informatics at University of Pittsburgh Medical Center (UPMC). The rationale is simple. Sixty-four slice CT is nearly ubiquitous. Consequently, radiologists are inundated with data with some scans generating nearly 10,000 images per study. Radiologists need to leverage every pixel of data to make the most informed diagnostic decisions. That’s where advanced visualization plays a starring role. “The only way to leverage new imaging technologies and modalities is to post-process slices into 3D datasets,” states Shrestha.
UPMC stands at the leading edge of enterprise advanced visualization. Like many large academic medical centers, UPMC uses an array of 3D solutions. Vital Images VitalConnect smart-client enterprise system is the hub of the center’s next-generation undertaking. Conventional 3D workflow can be inconsistent. That is, the radiologists’ efficiency hinges on the tech’s ability to appropriately route studies to the correct 3D workstation. If the tech does not push the data to the right workstation, the radiologist is stuck in manual query/retrieve process that hampers workflow. “Studies need to be consistently consistent,” says Shrestha. VitalConnect’s centralized server approach removes the inconsistency by intelligently routing studies to the appropriate point of care.
Like PACS, advanced visualization also runs a hefty (and growing) business outside the radiology department borders. “Smart-client is a paradigm shift in image delivery,” shares Shrestha. Prior to VitalConnect, radiologists maintained sole control of 3D data. They post-processed the images; typically selecting one or two snapshots to share with referring clinicians in the final report. VitalConnect completes the loop by sharing images and toolsets with referring physicians. Snapshots carry 3D functionality, which means clinicians can manipulate datasets as needed at their desktop. “It’s a tremendous value to cardiologists and other specialists like oncologists, surgeons and orthopedic specialists,” explains Shrestha.
The economic writing is on the wall. Hospitals and imaging centers will need to squeeze every drop of efficiency out of technology investments and human resources as possible. They need to boost service to referring physicians and patients to maintain a competitive edge. They need to build knowledge and best practices to enable better care and reduced costs. Well-deployed imaging and IT technology helps address the problem—cutting costs, improving service and enabling adopters to do more with stable or dwindling resources and effectively compete in the marketplace.