The “CD factory” had to go. That was the consensus reached four years ago by all parties involved in the handling of diagnostic images at the University of Rochester Medical Center (URMC), the regional healthcare hub in Western New York anchored by 800-bed Strong Memorial Hospital.

The internal nickname for the seven-person operation reflected its assembly line processes as well as its often frenetic pace. CDs came in bearing imaging studies not only from inpatient departments but also far-flung outpatient sites. Most of the discs were readable, but many were problematic—glitching up over image viewers if not the images themselves. Radiology staff members would upload the good ones into the PACS each day and then, in a massive annual cleaning, weed out the dross. Taken as a whole, the labor was a cumbersome and inefficient means of medical-image management.

And “CD indigestion” was only one reason URMC decided to go looking for a better way.

“As a quaternary medical center, we have a hub-and-spoke model, with about 19 smaller healthcare facilities in the area feeding in to us,” explains Jim Forrester, URMC’s director of enterprise imaging informatics.

“Until the summer of 2012, the spoke facilities, mostly hospitals but also urgent-care centers and a mobile imaging unit, connected to us mainly by business-to-business VPN tunnels. That was a major challenge to manage, because VPN tunnels are fairly complex and many of the smaller facilities lack IT staffing, expertise or both.”

What changed three years ago? URMC implemented a greatly simplified, technically superior image-management solution. Led by David Waldman, MD, PhD, chair of the department of imaging sciences, the institution selected LifeIMAGE. Secure and HIPAA-compliant, the system only requires end-users to open a browser and sign in. It was out with the CD factory, in with the cloud.

“Last January we were at over 110 percent census in the hospital with the flu epidemic,” recalls Forrester, describing LifeIMAGE in action. “Our stroke team was able to make clinical decisions based on imaging studies performed at regional hospitals. ‘Is there anything that only our medical center can do for this patient, or can they be best treated right where they are?’ We don’t want to bring patients into a medical center that’s already over census if they don’t need quaternary care. LifeIMAGE allowed us to make those calls quickly and accurately.”

Simplicity saves

For URMC, one of LifeIMAGE’s most persuasive selling points was its ease of use, which was apparent immediately upon implementation. Forrester and his team are happy to talk tech, describing how, for many use cases, the solution’s local app called LILA deploys open extensions to handle business objects in SQL queries. Working in conjunction with PACS, dedicated LifeIMAGE sending apps at the spokes facilitate DICOM routing, transferring image data to the cloud so URMC specialists can view and download it.

But team members are quick to point out that all of this advanced cloud computing is invisible to end-users.

“In the grand scheme of things, this really is quite simple,” says Paul Soto, URMC’s technical lead for regional IT services. “The site just has to have a computer or a virtual machine. We set up time with LifeIMAGE to install the sending app, and the spoke facility can be up and running in about an hour.”

Meanwhile LifeIMAGE requires minor software installation and allows CD uploading anywhere in the hospital by anyone who has password privileges. Clinicians at the hub and all the spokes can share the images without first pushing them into the enterprise PACS, and they can easily nominate a study for the EMR as well as the PACS.

Physicians love the time savings, which is “huge” at URMC, says Soto. “Typically it used to take up to 45 minutes to send imaging,” he adds. “That’s now down to under five minutes.”

Forrester notes that all URMC departments dealing with diagnostic images—not just radiology, cardiology and neurology but also orthopedics, surgery, pediatric cardiology, stroke center, trauma center and others—are now using the system. Some use it for outbound as well as inbound image sharing. This includes the Rochester-based Finger Lakes Donor Recovery Network, which must work nimbly with URMC to send and receive images of donor organs in order to evaluate transplant appropriateness for do-or-die patients on wait lists locally, regionally and, occasionally, nationally.

‘Just good patient care’

“We are projecting that, in the current fiscal year, URMC will generate and read approximately 580,000 imaging studies,” says Forrester. “In addition to that, we will ingest more than 58,000 foreign studies into LifeIMAGE."

Forrester adds that URMC uses LifeIMAGE as a screening tool, confident in the ability of the software’s viewer and workflow aids to let referring and ordering clinicians nominate studies to PACS. “Obviously we don’t import 100 percent of all studies that come in, but it’s about 70 percent,” he explains. “If the ordering clinician wishes to use that imaging study for clinical care, why not ingest it into PACS?” There is cost associated with this application of the technology, he says, but the option can save time, reduce duplicate radiation dosage and cut the economic cost of doing duplicate imaging studies.

“It makes sense for us to have it,” says Forrester. “It’s just good patient care.”

Soto describes an illustrative case in which a patient arrived at URMC from a regional facility that was not yet a URMC spoke and so wasn’t set up with a LifeIMAGE sending application. The patient was a child presenting symptoms of acute appendicitis. The parents were well informed on, and rightly concerned about, radiation dosage associated with CT. A scan had been performed at the regional site, but the CD had been lost somewhere between there and URMC, a 90-mile ambulance ride away.

“We gave the regional facility one-time, on-demand credentials for the cloud service,” says Soto, adding that such transactions have become common. “The facility sent us the study, and the surgeon was able to use the images and make a determination on the appendicitis. We completely avoided duplicate imaging and unnecessary dosing. And this stuff happens every day now.”

From a better way to the only way

Forrester stresses three pointers that have proven key to URMC’s success with LifeIMAGE, inviting other provider organizations to draw from the learnings:

• Aim for appropriate design. URMC appointed a workflow expert to customize processes around LifeIMAGE’s suite of features and, on an as-needed or ongoing basis, to work with imaging orderers and referrers in fine-tuning their unique workflows. “Orthopedics uses image-sharing tools differently than trauma, peds cardiology differently than stroke center, and so on,” says Forrester.
• Set up a dedicated team. Forrester explains that URMC’s LifeIMAGE implementation team was made up of just two people. The goal was to make sure more than one individual knew the platform’s possibilities and could pass on the know-how to imaging orderers and help them surmount any hurdles. “And by the way, the hurdles often turn out to be perceived,” he adds, “not actual.”
• Organize an oversight or governance structure to facilitate leveraging your LifeIMAGE investment as an enterprise platform. “Our governance structure brings in senior leadership, which has allowed us to capture use cases that might have gotten missed,” says Forrester. “At a large institution, people may not realize that you have an enterprise solution” even after it’s been up and running for quite some time.

Speaking to that last point, Mary Thomas, who was URMC’s director of imaging informatics at the time of the LifeIMAGE go-live and now consults as lead workflow analyst, emphasizes the need to communicate across the enterprise—but largely for the opposite reason of non-awareness.

“Assume that LifeIMAGE will become a mission-critical system for your institution, with urgent patient-care activities relying on it,” she says.

Forrester concurs. He recalls a pressing phone conversation with the ER director this past January. LifeIMAGE was slated for an upgrade, and the director asked if it could be scheduled for 2 a.m. Monday—the heart of off-peak hours—to avoid living without the system any more than necessary.

“It has become so effective that we forget what it was like when those CDs would come in and we couldn’t read the study or we couldn’t load the viewer,” he says. “Now our LifeIMAGE application is replicated in real time across our data centers as a critical application.” Fortunately, the widespread clinical reliance has led to real IT readiness. “If we ever lose the hardware,” says Forrester, “we’ll have the system back up within half an hour.”