You don’t have to work in a large hospital to take full advantage of enterprise-wide PACS. Exeter Hospital, a 100-bed community hospital in Exeter, N.H., is thriving proof of how smaller, community hospitals can afford and benefit from PACS by streamlining workflow and increasing department and staff efficiency.
By installing Agfa HealthCare IMPAX version 5.2 and IMPAX for Cardiology combined with web-based PACS, physicians and technologists at Exeter attained a more streamlined facility, prevented the loss of x-ray films, saved storage space, eliminated chemical processing of film and the cost of film, and were able to access images from all modalities in one place, at any time.
Managing rising image volume
This community hospital caters to a large summer population in southern New Hampshire and northern Massachusetts, and parts of southern Maine. The year-round population is also growing and aging, contributing to a surge in imaging procedures each year. During the time that they were still debating whether to purchase PACS, they saw imaging volume grow from 41,600 imaging studies in 1998 to 47,400 a year later, and by 2000, the hospital completed 52,000 imaging studies — showing a 25 percent increase over two years. In 2006, after Agfa IMPAX had been installed for three years, they performed approximately 88,000 radiology exams.
“In the late ‘90s, we realized that the growth within our communities was continuously increasing,” says Lisa Martelli, PACS system administrator at Exeter. To manage the increase in population and exam volume, in 1999 the hospital began planning a multiphase expansion which included a new building at the front of the main hospital that would offer outpatient services including the women’s imaging center for ultrasound, x-ray and mammography, out-patient radiation oncology, medical oncology, endoscopy, and surgical services. That split the diagnostic imaging department between two different sections on opposite ends of the hospital. Physicians and radiologists were concerned about how they would handle going back and forth between the two separate departments for image distribution. “That led to the discussion of PACS,” Martelli says. “We knew with the expansion of the hospital and the increase in our volume, we would need to revise our workflow to continue offering excellent customer service by providing our patients and physicians with results in a timely fashion.”
Exeter also was running out of storage space due to increased exam volume and larger image studies for CT and MRI. “It used to be chaos.” Martelli recounts, “Pre-PACS, we had x-ray jackets stored in many different rooms. Films had the potential to be misfiled and not readily available upon request.”
Pre-planning PACS execution
To resolve these issues, a PACS development team began to discuss an enterprise-wide PACS solution, which meant that all digital images from radiology and cardiology would be available in any hospital location via PACS. In 2001, David Briden, Exeter Hospital’s vice president and CIO, met with the facility’s CEO, CFO, and board of trustees to propose the plan. Upon approval, Martelli began the year-long process of researching vendors and attending radiology shows to find a system that would meet their needs. They were initially interested in eight vendors and invited them to Exeter hospital for presentations. The PACS team then narrowed it down to three vendors and asked each vendor to conduct a hands-on workshop to demo their systems to physicians and staff. After the demonstrations, the field was narrowed to two vendors. The PACS team then hit the road on site visits to facilities of similar demographics that were using the system.
Agfa IMPAX won a unanimous decision of the PACS team, coming out on top for several reasons — one being Agfa’s willingness to interface with the facility’s Meditech hospital information system (HIS) and electronic medical record (EMR) which was already in place for referring physicians to access medical reports, laboratory values, and other information on their patients.
“We found that Agfa stepped up and took the initiative to want to [interface the Meditech system] and make it work for us,” Martelli says. A second reason was that Agfa was able to interface with the cardiology department, which was very important to the hospital because they wanted to combine radiology and cardiology without having to buy a separate image management system, according to Jennifer Mulholland, principal systems analyst at Exeter Hospital.
Another nod for Agfa came when they took the time to analyze Exeter’s workflow to devise a cost-effective solution for viewing images. While other vendors recommended the hospital purchase an abundance of workstations, which would have been very expensive and dominate valuable space within the hospital, Agfa suggested using the Agfa web browser so physicians could access images through the hospital’s Meditech EMR via the web on a regular PC. “It really didn’t make sense for us to invest money in these extra workstations and distribute them around the hospital since the majority of our medical staff uses Meditech to access patient information” Martelli says.
This solution allowed Exeter to deploy only five diagnostic workstations for radiologists (three in the main radiology department and two in the outpatient clinic), and four clinical review stations (two in the emergency department, one in the special care unit, and another in the diagnostic imaging department’s front office). “It lowered the cost of the investment and still allowed us to provide our physicians with quality images” she added.
The light at the end of the tunnel
It took 18 months to research vendors, make a decision, sign with Agfa, and go live. The PACS was installed and ready for use in March 2003. Exeter Hospital phased in the implementation by first interfacing the ultrasound department to familiarize physicians with the system, moving on to other departments over the next few months. “We did it slowly to give everyone time to learn and to be trained properly. That way we could work out any bugs in the system, instead of having all the departments go live at once,” Martelli says.
Agfa was on-site at several points to offer hands-on training. Physicians received one-on-one IT training that included instruction on network access, use of the Meditech system and a demonstration of the Agfa web application. In addition, a user guide took the reader through basic functions of the application.
For long-term archiving, the PACS utilizes an EMC Centera (Gen 4, software version 3.0.3) that features 8 terabytes (TB) of storage space. It also provides redundancy by automatically duplicating every piece of stored data. An EMC CLARiioN storage area network (SAN) takes care of short-term storage, making two years of data easily accessible via PACS.
Adapting to new technology
Implementing PACS also allowed Exeter Hospital to decrease the amount of time needed to interpret breast MRI examinations. “If we didn’t have PACS, it would take the radiologist up to an hour to read these studies because there are over 1,000 images [per exam], which is over 100 sheets of film,” Martelli says. “PACS allows us to scroll through and manipulate these images very quickly on the workstation.”
They’re also going to be adding digital mammography in August, which will make images available in PACS for the radiologist and referring physicians to examine. They’re also planning an upgrade to the next version of IMPAX 6.2, which will be web-based. All clinical users will have the same image access and manipulation tools as the radiologist.
“Luckily, we have a CEO who has a great vision, who wants to stay on the leading edge of technology and stay ahead of the competition,” Martelli says. “It’s the vision and goal of the hospital to stay a leader in our region and on the leading edge of technology. This vision gives us the ability to follow through with projects such as this.”