A need for imaging and IT systems that would allow for significant growth, improved service and state-of-the-art technology led a forward-thinking, Georgia-based healthcare organization to implement PACS, go filmless and drive better productivity. Two vendors partnered to establish a digital platform and the storage, archiving and monitoring systems needed to keep it running smoothly.
WellStar Health System, the largest not-for-profit hospital system in Georgia, serves one of the fastest-growing counties in the state—Cobb County—and three adjacent counties in the Atlanta area. WellStar was established in 1997 and has been growing ever since. The system now includes five hospitals, multiple associated physician groups and urgent care centers, and 10 imaging centers.
A strong product line
WellStar decided to implement PACS and become filmless to improve its service to referring physicians and patients. “We wanted to reduce competition inside the hospitals between ED patients, inpatients and outpatients for services. At the same time, we recognized that outpatient imaging would be a strong product line for us,” says Robert Mandler, executive director of medical imaging.
WellStar also wanted the ability to offer state-of-the-art medical technology. “When we started looking at investments in technology, we wanted to make sure we had the electronic infrastructure to support our investments.” A digital environment would provide the foundation needed to let the organization install the most advanced imaging modalities.
The effort began with two new imaging centers designed to be digital from day one, says Mandler. Soon after construction began, WellStar contracted with Agfa HealthCare to install the digital technology and provide IMPAX PACS as an application service provider, while leveraging an EMC information infrastructure. Mandler says WellStar chose Agfa because of the company’s ability to integrate multiple legacy systems.
Agfa’s IMPAX Basix system was installed to accommodate the transfer of digital information. The first two imaging centers opened equipped with Agfa’s IMPAX Basix Server with RAID (redundant array of independent disks) on-site storage, an IMPAX Basix dual black-and-white diagnostic station and multiple CS 5000 clinical review stations. The two centers also had the Agfa Diagnostic Center (ADC), a complete computed radiography package that was installed at each of the eight other new imaging centers WellStar built. Two more have been added since then.
Agfa linked WellStar’s existing digital images and RIS to the Basix with a broker data center so that prior studies would be automatically available with any new studies. Agfa also installed its web server, IMPAX WEB 1000, to transport all images and reports to referring physicians. This set-up was replicated at each of the new imaging centers.
WellStar decided that an enterprise-wide PACS would best maximize efficiency and productivity. A central Oracle server and database archive linked each facility. One key advantage with Agfa, Mandler says, is its consistency over the years. “Almost every other major PACS vendor out there has made acquisitions or completely changed their platform.” Since starting to purchase Agfa equipment in 2001, none of the systems have become obsolete so “we’ve had no ‘sunk funds.’”
Getting up to speed
To get all of the physicians up to speed with the new equipment, marketing representatives worked with each practice, says Carol Scoggins, WellStar’s director for radiology informatics and marketing. The reps helped physician practices learn how to load images, pull them up on their computers and use the various tools.
Another part of the job is to periodically check in with practices to promote services and make sure WellStar is meeting their needs, from training to order forms to patient information brochures. These are positions Scoggins “definitely recommends” for a large, diverse organization.
The initial issue was getting the images out to physician practice, says Scoggins. “Practices had variations in their connectivity and their computer systems.” That ranged from DSL to dial-up connections to one practice that did not even have one computer—everything was done manually. “It was eye-opening for us just as much as it was for them,” she says. She and her team worked internally as much as possible to allow for easier image access through the physician portal and some practices upgraded their systems. “Physicians upgrading their systems is really only an investment in themselves.”
Some practices had trouble when downloading—something from the internet might have a higher version of Java than what the practice had so the two versions were competing with each other. Between the marketing reps, WellStar IS staff, Agfa employees and high acceptance of WEB 1000, most users have no problems.
Once the marketing representatives got the practices set up and familiar with the equipment, PACS administrators, like Becky Hayslett, help with ongoing support. She goes out and helps physicians with personal computers and helps with any problems regarding access.
Meanwhile, the digital infrastructure and PACS was phased in at each of WellStar’s five hospitals. When the conversion began at the hospitals, there were significant differences from working at the imaging centers. “You’ve got the ED, critical care, and everything is larger scale,” says Scoggins. “At Kennestone and Cobb, there are massive volumes of imaging going through those facilities.” The CS 5000 viewing stations were installed in all the EDs and critical-care units. Lastly, PACS was implemented in all the ORs so that surgeons have all necessary information immediately available.
The phased-in approach presents its own set of challenges, says Mandler. “Ideally, the best way to turn PACS on is overnight to get the highest rate of return. Ours is a large operation to take digital. Moving in the fashion that we did presented a lot more issues than if we were able to just turn a switch and go from a digital to film environment almost overnight. The longer the transfer from film-based to digital takes, the more problematic it will be because you have to deal with a sort of duplicate environment, where some images come out as film and some as digital.”
Managing the information
As WellStar’s expansion and conversion progressed and the organization needed to expand its archive, Mandler developed a central Oracle database server with an EMC Centera active archiving system and EMC CLARiiON storage area network (SAN). “That allowed us to continue to grow. We now have 70 terabytes (TB) in the primary archive. Approximately one year’s worth of data are stored locally at each of 15 operations on EMC CLARiiON. “That gives us the performance we need inside each local imaging center and the backup for images on demand from the [EMC] Centera archive.”
Agfa’s relationship with EMC led to WellStar’s growth from 3 TB to 70 TB. Back in 2001, “we considered our growth expansion through 2005,” says Mandler. In 2001, WellStar was performing approximately 500,000 studies a year. By the time WellStar finished eight imaging centers and its conversion to digital imaging, the organization was experiencing 5 to 6 percent annual growth and performing almost 700,000 imaging studies a year. Installing 13 digital mammography units to replace 18 analog systems led to another reprojection of archive growth. “Digital mammography produces a lot of data,” Mandler points out.
The addition of digital mammography didn’t even cause “a blip on the radar screen” thanks to the WellStar information infrastructure created with Agfa and EMC, says Mandler. “We were able to absorb the increase in activity on the network and disk storage space required to archive digital images from mammography. That was all done through the cooperation of WellStar’s IT department, Agfa PACS and EMC.”
Scoggins says that the ability and flexibility to have a study performed at one facility and read by a neuroradiologist at another, if necessary, “is a bonus for the patient and for patient care.”
“Agfa has helped us become more productive and provide better patient care,” says Hayslett. “When you have an electronic image, it’s easier to get information to referring physicians so they know how to treat patients in a timely manner.”
Some physicians have told Mandler that the system has totally changed the way they practice medicine. Plus, “there’s no way radiologists could manage the data-intensive studies, such as coronary CT angiography, without it.”
Due to the shortage of radiologists, “we want to make radiologists as efficient as possible,” he says. The ability to move images around and have priors immediately available “really maximizes the radiologists’ ability to read patient studies,” says Scoggins.
She uses Agfa’s IMPAX SMMS (System Monitoring & Management Services) to track usage. The CS 5000s have the highest utilization in the ICUs and EDs. She also can see that the EPR suite, which provides physicians with a single login on the physician portal, is highly accepted. “With SMMS, we can see that there’s acceptance in all the critical key areas we were promoting and training.”
Today, Mandler is planning for an upgrade of the Agfa IMPAX platforms to version 6.X. “We’re also looking to replace our existing RIS with a RIS that will be more fully integrated to fully enhance our workflow with PACS,” he says. Another effort is continuing to expand the archive based on image volume. Meanwhile, he’s working on a business continuity plan and a secondary archive that is economically efficient for studies that are three-to-five years old.
“Overall, we’re happy with the system,” Scoggins says. “The ability for our clinicians to access images and reports on line is tremendous benefit to patient care,” says Mandler. “Wherever they go, images and reports are available to clinicians.”