Inside a RHIO: Maine Health System Spreads the Imaging Wealth

 Small, rural hospitals often have trouble supporting their own PACS and full-time radiology coverage. By offering its radiology, RIS and PACS resources to others on an outsourcing basis, Eastern Maine Medical Center has prevented unnecessary transfers, duplicate studies and enabled the faster commencement of critical treatment.

Eastern Maine Medical Center (EMMC) in Bangor has leveraged its radiology RIS and PACS equipment into the infrastructure of a regional health information organization (RHIO). EMMC is the tertiary referral center and hub of the six-hospital Eastern Maine Healthcare System (EMHS). EMMC went live with RIS in 1998 and PACS in June 2002, and started rolling it out to other sites in June 2004, says Deborah Sanford, RN, MS, patient care administrator. Beyond those six hospitals, Sanford says that the majority of the organizations in the RHIO are nonaffiliated. The RHIO facilities extend more than 200 miles from Presque Isle in the north to Waterville, southwest of Bangor.

One RIS that EMMC uses is the Agfa HealthCare IMPAX Radiology Information System and IMPAX Master Patient Index, which are integrated with the IMPAX PACS. Agfa assisted the facility in setting up the imaging RHIO which included supplying staff to help with implementation and “setting up regional architecture to best meet the needs of the patients and institutions participating,” Sanford says.

Facilities came on board as they were ready with more hospitals on schedule for later this year. Each hospital has to have the IT structures in place, financing and CR to enable digital images. “Most didn’t have CR and that was the largest cost for the organizations,” Sanford says. Sanford’s IT team and IT professionals from Agfa conducted both a network and a technology review to determine exactly what was required. Each hospital needed a server with which to pull DICOM images so they didn’t have to retrieve images over a T1 line. EMMC built everything up to a hospital, and then that hospital was responsible for building its internal network and ongoing management. Sanford also worked with each hospital’s imaging equipment vendors to help the facility get DICOM ready. In some cases, her team worked hand-in-hand with the facility and in others, the facility took care of the changes more independently.

Expanding radiology coverage

The RHIO was initiated to address the unique needs of a rural, sparsely populated region. EMHS’s referral area is the upper two-thirds of the state and includes 434,000 covered lives. Over the past two-and-a-half years, EMMC has enabled several smaller hospitals — 20-, 30-, and 40-bed facilities — that cannot afford their own PACS to take advantage of its system.

“A majority [of the facilities] are critical-access hospitals so they can’t support a full-time radiologist,” explains Sanford. “A lot are looking at not having radiology coverage.” Since beginning to share the PACS, the hospitals can support 24/7 imaging with timely interpretations and delivery of patient care. “We also have seen a decrease in unnecessary transfers to tertiary care centers because basic diagnostic imaging services are now available around the clock,” she says. The smaller hospitals have “hopped onto our PACS. We’ve been able to leverage our infrastructure and provide them with local caching and image management at their local site. They don’t have to have full-time information technology staff there.”

EMMC signed on with Agfa in October 2001, implemented its PACS solution in 2002 and its RIS in 2006. “We fell into this RHIO by accident,” Sanford says. The hospital’s radiologists are fairly progressive, she says, and realized that the benefits of the RIS and PACS at EMMC did not exist at the other hospitals they covered. “They said, ‘The smaller sites can’t afford this, but we should be able to leverage what we’re doing here.’” That turned into a centralized communication and support system. “People think you have just a centralized archive, but what we really have is a communication system of imaging results,” she says. Because both images and reports are accessible, providers around the state can see what’s happening with their patients, wherever they are.

Saving time, money, travel

People no longer have to make overnight trips to Bangor for imaging procedures because they can have the exams done locally and transmitted for interpretation. The referring doctors can access the images and reports anytime, anywhere. Conversely, if the patient is in a car accident or experiences other trauma, the ED clinicians can retrieve relevant patient information from the patient’s primary care provider. “It’s that longitudinal imaging health record,” Sanford says. “There are not many people doing it from an electronic medical record perspective, and there are very few doing it from an imaging perspective.”

Eastern Maine Medical Center in Bangor is the tertiary referral center and hub of the six-hospital Eastern Maine Healthcare System, a regional health information organization (RHIO) that serves facilities over a 200 mile area from Presque Island in the north, to Waterville that is southwest of Bangor.The benefits garnered from this interconnectivity are “critical to maintaining the health” of Maine residents. “It’s allowing people to get the specialty and primary coverage they need closer to their homes. They don’t need to travel for their healthcare.” Sanford says healthcare costs have gone down because fewer repeat studies are needed. For example, it wasn’t uncommon for patients to be transferred but then arrive at another facility without their imaging studies. An abdominal CT or other high-end imaging study would have to be repeated. Fewer repeat exams also are safer for patients and insurers appreciate the reduction in unnecessary studies.

Another time-and-money saver has been the ability to avoid unnecessary transfers between hospitals. In some cases, imaging studies help determine whether a patient with a head injury or a questionable bleed needs neurosurgical intervention. Clinicians at the smaller hospital can perform an advanced imaging study, transmit it to the tertiary care center for interpretation, and then receive word that the patient does not need to be transferred.

This same process is very helpful for possible stroke patients. Often someone comes in with a questionable ischemic stroke, Sanford says. Unfortunately, in many smaller facilities, the ED provider is a mid-level practitioner — physician’s assistant, nurse practitioner or a family practice doctor with varying levels of expertise in reading images, she explains. These providers are reluctant to start tPA (tissue plasminogen activator), a clot-busting drug most effective when given within three hours of ischemic stroke, because giving the drug to the wrong patients can seriously worsen their condition. “Caregivers lacking expertise in this area can maximize specialists around the region to make those decisions,” Sanford says. “tPA can be started in the ED at smaller hospitals to meet the three-hour window and yield better patient outcomes.”

Positive feedback all around

Sanford says that the positive feedback from patients has included no longer needing to travel to Bangor and stay overnight, and not having to be responsible for transporting their films. The ability to stay up-to-date with the latest steps in their treatment is appreciated as well. A cancer patient, for example, can talk to his or her specialist about exams performed locally to find out the next treatment step. As positive as patients have been, Sanford says the medical staff has been even more appreciative. Physicians from remote areas can tap into subspecialists' expertise at EMMC when a patient has a problem that probably can be diagnosed with an imaging study. “If they’re 150 miles away and it’s a Tuesday night, they know that they can have a specialist at EMMC take a look and give some feedback,” she says. 

Since 48 percent of inpatients at EMMC are not local, physicians — including trauma specialists and intensivists — appreciate the ability to start treatment planning as a patient is on their way to the hospital. “They can start doing measurements and have everything ready. When the patient gets here, surgical candidates are rolled directly in.” Plus, with half of the medical staff in private practice, they also can retrieve images in their offices so they can do some planning and pretreatment tasks.

An added benefit of EMMC’s integrated RIS-PACS-Master Patient Index is the ability for any organization to use its own medical record numbers. Typically, the originating practice or facility would have to adopt the hospital’s medical record number. “We could leverage some newer technologies that came down the line to allow a master patient identifier to be put on top of patient data, so no matter where you are you can use your own medical record number,” Sanford says. Agfa’s IMPAX MPI is integrated with Initiate Identify Hub software which uses sophisticated algorithms to cross-reference patients identifiers, thereby unifying the management and delivery of patient imaging studies across connected facilities. The product was something EMMC set up specifically for this RHIO.

Looking back at these efforts, Sanford says that technologically, she wouldn’t have done anything differently. She and her team spent considerable time with the imaging and emergency departments at connected facilities to understand their workflow. Given the success of this effort, EMMC now is in the process of evaluating the ability of hooking their PACS archive up to that of Maine Medical Center in Portland, which covers the smallest geographical area in the state but the most lives. That will extend the reach and create a truly statewide RHIO.

Eastern Maine Medical Center: Up close
Eastern Maine Medical Center (EMMC) is located in Bangor, Maine, and has served communities throughout central, eastern, and northern Maine for more than a century, growing from a five-bed general hospital to a 411-bed comprehensive medical center. The medical center and its medical staff of nearly 300 physicians provide three-quarters of the primary care hospital services offered in the Bangor area, as well as specialty and intensive services to the northern two-thirds of the state.

EMMC is a member of Eastern Maine Health System, the second-largest tertiary care system in the state. The facility employs 2,800. EMMC also provides outreach clinics to many local hospitals in the region, allowing easier access for patients and supporting the role of those hospitals in their communities.

In 1998, EMMC become one of three designated trauma centers in the Maine Trauma System, a voluntary trauma response network involving all Maine hospitals and the state’s emergency medical service.

The facility also features the EMMC Clinical Research Center, a multidisciplinary collaborative geared to enhancing services and patient care. Current areas of study include telehealth, bariatric surgery, chemotherapy outcomes and the use of electronic health records.